THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


GIFT 

of 
MRS.   J.    R.   WALKER 


/ 


TEXT-BOOK     ON 


S  U  E  G  E  R  Y 


GENERAL,   OPERATIVE,   AND    MECHANICAL 


BY 


JOHN   A.    AYYETH,   M.D. 


PROFESSOR  OF  SURGERY   IN  THE  NEW  YOKK   POLYCLINIC  ;    SURGEON  TO   MOl^NT  SINAI   HOSPITAL  : 

CONSULTING    SURGEON    Tu    THE    YORKVILLE    DISPENSARY    AND    HOSPITAL    FOR    WOStEN    AND    CHILDREN  : 

TO  THE   woman's   HOSPITAL  OF  BROOKLYN  ; 

EX-PRESIDENT  OF  THE   NEW   YORK    PATHOLOGICAL  SOCIETY  : 

UEUBER  OF  THE    NEW   YORK   SURGICAL  StfCIETV  :    OF  THE   ACADEMY    OF   MEDICINE  : 

OF  THE    NEW   YORK    STATE    MEDICAL    ASSOCIATION  ;    OF  THE   NEW   YORK   COUNTY    MEDICAL  StXIETY  ; 

HONORARY    MEMBER  OF  THE  TEXAS  STATE    MEDICAL  ASSOCUTION  ; 

OF  THE  COLLEGE   OF   PHYSICIANS  AND  SURGEONS    OF   LITTLE    ROCK.    ARKANSAS. 

AUTHOR    OF   AN    ESSAY   ON    THE    SURGICAL   ANATOMY    OF   THE    TIBIO-TARSAL    REGION, 

WITH    SPECIAL    REFERENCE    TO    AMPUTATIONS    AT    THIS    JOINT. 

AWARDED  THE  JAMES   R.   WOOD  ANNUAL  PRIZE   OF  THE  BELLEVUE  ALUMNI   ASSOCIATION.    IWR  ; 

AN    ESSAY    ON    THE    St'RGlCAL    ANATOMY    AXD    HISTORY    OF    THE    CAROTID    ARTERIES. 

AWARDED  THE    FIRST   PRIZE   t)F  THE   AMERICAN    MEDICAL  ASSOCIATION.    187K  ; 

AK   ESSAY   ON  THE   SURGICAL  ANATOMY    AND    HISTORY   OF  THE    INNOMINATE   AND   SUBCLAYIAN   ARTERIES, 

AWARDED  THE  SECONT)  PRIZE   OF  THE  AMERICAN  MEDICAL  ASSOCIATION.    1878.   ETC. 


NEW    YORK 

D.    APPLETON    AND    COMPANY 

1889 


COPTRIOHT,    1887, 

Bt  d.  appleton  and  company. 


iiliraor 


100 


TO     THE     MEMORY     OF     MY     FRIEND, 

J.    MAEION    SIMS,    M.  D.. 

WHOSE   BRILLIANT   ACHIEVEMENTS   CARRIED 

THE      FAME      OF      AMERICAN      SURGEEY 

THROUGHOUT    THE    CIVILIZED    WORLD. 

THIS    BOOK     IS    AFFECTIONATELY    DEDICATED 

BY     THE     A  I  T  H  O  R  . 


P  REFAO  E 


The  author  lias  endeavored  to  give  in  the  following  pages  the 
accepted  facts  in  surgical  pathology  and  diagnosis,  together  with  the 
methods  of  treatment  which  modern  surgery  has  introduced,  or  has 
elected  as  worthy  of  continued  application  from  the  practice  and 
teaching  of  the  past.  In  the  effort  to  condense  into  a  single  volume, 
of  about  eight  hundred  pages,  the  essentials  of  the  science  and  art  of 
surgery,  not  only  is  a  discussion  of  theories  out  of  the  question,  but 
many  measures  of  treatment— the  comparative  usefulness  of  which  has 
been  demonstrated— must  of  necessity  be  omitted. 

In  an  age  when  books  upon  this  subject  are  plentiful,  this  work 
was  undertaken  not  without  misgivings,  yet  with  a  determination  to 
leave  nothing  undone  which  would  add  to  its  usefulness  and  make  it 
an  exponent  of  modern  and  progressive  surgery.  Such  rapid  advances 
are  being  made,  that  marvelous  results  are  to-day  achieved  by  meas- 
ures unknown  to  the  profession  but  a  few  months  earlier.  The  intro- 
duction of  cocaine  JiydrocMorate  as  a  local  anaesthetic  marks  an  epoch 
in  surgical  practice ;  and  yet  this  wonderful  agent  has  scarcely  been 
mentioned  in  works  on  surgery.  Again,  the  antiseptic  method  of 
treating  wounds,  originated  within  the  last  few  years,  has  brought 
with  it  such  protection  to  life  and  usefulness,  that  it  deserves  a  more 
thorough  consideration  than  is  often  allotted  it  by  surgical  writers, 
and  should  be  universally  accepted  and  practiced. 

The  author  believed  that  the  general  profession  was  not  sufficiently 
impressed  with  the  dangers  in  delaying  surgical  interference  in  lesions 
of  the  cavities  and  their  viscera,  notably  the  craniiim,  abdomen,  and 
pelvis.  These,  and  other  considerations  which  will  be  found  in  the 
text,   were  among   the  reasons  which  led  him  to  hope  that  this  book 


*^07^27 


vi  PREFACE. 

would  prove  acceptable  to  his  fellow-workers,  and  especially  to  that 
numerous  class  of  physicians  who  are  compelled  to  do  a  general  prac- 
tice, and  who  can  lind  neither  time  nor  opportunity  to  select  from 
the  vast  quantity  of  surgical  literature  the  facts  essential  to  the 
prompt  and  successful  management  of  their  cases.  That  this  hope 
was  not  without  foundation  is  attested  by  the  reception  accorded  to 
the  work  by  the  medical  press,  and  by  the  necessity  of  a  second  issue 
within  three  months  after  its  publication. 

To  the  many'  sources  fi'om  which  much  needed  help  in  its  com- 
pilation and  illustration  was  obtained — however  accredited  in  the  text 
— the  author  desires  to  acknowledge  an  especial  indebtedness,  and  to 
the  engravers,  Messrs.  H.  Senior  and  Company,  for  the  general  excel- 
lence and  pi'ompt  execution  of  their  work.  An  examination  of  the 
volume  will  attest  the  liberality  of  the  publishers,  who  have  contrib- 
uted greatly  to  its  success. 

The  Author. 

April  20,  1887. 


COI^TENTS. 


CHAPTER  I. 

PAGE 

Surgical  dressings — Ligatures  and  sutm-es — Preparation  of  material — Silk,  silk-worm  gut,  silver 
wire — Antiseptic  solutions — Corrosive  sublimate,  carbolic  acid,  iodoform,  alcohol,  chlovide- 
of-zinc — Irrigators — Sponges — Drains:  rubber,  bone,  catgut,  and  horse-hair — Protective 
— Carbolized,  sulilimated,  and  iodoformized  gauze — Borated  and  absorbent  cotton — Peat 
— Sawdust — Jute — Wood-wool 1 

CHAPTER  II. 

Bandaging — Materials  and  methods  of  preparing — Application  of  the  various  methods — Simple 
spiral,  reverse  spiral,  figure-of-8  turn,  figure-of-8  reverse — Hand  and  fingers — Forearm, 
arm,  and  shoulder — Toes,  foot,  leg,  and  thigh — Spica — Head  and  face — Knotted  bandage 
— Handkerchief  bandages 9 

CHAPTER  III. 

Anajsthesia — Local  anaisthesia — Cocaine — Ether-spray — General  anesthesia — Administration 
of  ether  by  inhalation — By  the  rectum — Chloroform  and  chloroform  narcosis     .        .        .21 

CHAPTER  IV. 

Surgical  operations — Instruments — Operating  -  table — Furniture — Operating -gown — How  to 
hold  the  scalpel — Hienjostasis — Tying  the  ligature — After-treatment  of  the  case         .        .    34 

CHAPTER  V. 

Inflammation — Venesection  and  blood-letting — Compression — Application  of  cold — Internal 
medication — Suppuration — Pus — Slicrococci — Bacteria — Abscess — Treatment    .        .        .53 

CHAPTER  VI. 

Wounds — Process  of  repair — Cicatrization — The  tourniquet — Closing  wounds — The  inter- 
rupted, continuous,  mattress,  quill,  wire,  and  pin  sutures — Transfusion — Intra-venous  in- 
jection of  a  saline  solution — Poisoned  wounds — Snake-bite — Tarantula-poison — Wounds 
by  bees,  wasps,  hornets,  and  centipedes — Hydrophobia — Glanders — JIalignant  pustule — 
Dissection  wounds  —  Erysipelas  —  Dermatitis  —  Erythema  —  Cellulitis  —  Tetanus  —  Shot- 
wounds     65 

CHAPTER   VH. 

Bums  and  scalds — Skin-grafting — Frost-bite — Furuncle — Carbuncle — Ulcers — Gangrene — ^Dry 
or  senile  gangrene — Hospital  gangrene 90 


viii  CONTENTS. 

CIIAPTKK    Vlir. 

PAGE 

Amputations — Method  of  operating— Circular  solid  ll.ip.  with  perpendicular  slit — Obliipic 
solid  flaps  by  transfixion — The  same,  bv  cutting  from  the  sm-face  inward — Skin-flaps — Cir- 
cular method — Modified  circular — Oval — Double  cresccntic — Double  rectangular — Mixed 
flaps  —  Open  method — Special  amputations — Fingers — Hand — Forearm — Klbow-joint — 
Arm — Shoulder — Toes — Through  the  metatarsus — Through  the  tarsus — Methods  of  I'iro- 
gofT,  Chopart.  Forbes.  Hey.  Lisfranc,  Le  Fort,  Lignerolles,  and  Hancock — Tibio-tarsal 
disarticulation — Method  of  Syme— Leg — Method  of  Stephen  Smith— Knee-joint— Thigh— 
Hip-joint — Method  of  Ersljine  Mason,  etc 103 

CHAPTER   IX. 

Surgical  diseases  and  surgery  of  the  lymphatic  vessels,  veins,  and  arteries — Lymphangitis — 
Adenitis— Phlebitis — Arteritis — Arterial  thrombosis  and  embolism— Vascular  tumors — 
Arterial  varix — Cirsoid  arterial  tumor — Angeiomata — Venous  varix  or  varicose  veins — 
Moles — Port- wine  mark 158 

CHAPTER  X. 

Aneurism — Varicose  aneurism — Aneurismal  varix — Method  of  Tnfnell  and  Valsalva — Tjigature 
by  the  methods  of  Antyllus,  Wardro]).  Anel.  Hunter,  and  Brasdor — Digital  and  mechan- 
ical pressure — Galvano-puncture,  massage,  flexion,  introduction  of  wire,  horse-hair,  catgut, 
etc. — -Aneurism  of  the  thoracic  aorta — Innominate — Common  external  and  inti'rmil  ca- 
rotid arteries — Subclavian — Abdominal  aorta— Iliac  arteries — Femoral — Popliteal     .        .  198 

CHAPTER   XI. 

Ligation  of  arteries — Innominate — Common,  external,  and  internal  carotid  and  internal  jugu- 
lar vein — Superior  thyroid,  lingual,  facial,  ascending  pharyngeal,  occipital,  ])Osterior 
auricular,  temporal,  and  internal  maxillary— Subclavian— \'crtebral  and  internal  mam- 
mary— Axillary — Brachial — Radial — Uliuir — Intercostal — Abdominal  aort.a — Iliac  arteries 
—Gluteal,  internal  pudie,  and  sciatic— Femoral— Profunda  femoris— Popliteal— Poste- 
rior tibial — Anterior  tibial — Dorsalis  pedis 230 


CHAPTER   XII. 

Surgical  diseases  and  surgery  of  the  bones— Ostitis— Osteo-iieriostitis-Osteomalacia-Rachitis 
—Fractures— Of  the  skull— Trephining— Nasal  l)ones— Malar— Superior  nuixilla- Inferior 
maxilla— Clavicle— Acromion  and  coracoid  process— Glenoid  process— Spine  of  the  scapula 
—Humerus — Comlyles — Olecranon  process — Ulna — Radius — Colles's  fract ure — Carpus— 
Metacarpus— Phalanges— Sternum— Ribs— Vertebrie— Sacrum— Coccyx— Osinuominatum 
—Femur— Patella— Leg— Potfs  fracture— Tarsus  and  metatarsus— Ununited  fractures     .  371 


CHAPTER    XIIT. 

Surgery  of  the  articulations- Dislocations— Lower  j.iw-Claviclc-Shoulder-joint— Elbow- 
joint — Wrist-joint  —  Carpo-metacarpal  joints — Phalanges  —  Hip-joint  —  Knee- joint— Pa- 
tella—larsus—A'ertebr,T— Ribs— Arthritis— Hip-joint  disease,  or  mnrhua  cara-— Knee- 
joint  disea-sc— Ankle-joint— Shoulder-joint— Elbow-joint— Wrist-joint— Exseetions  of  tin- 
joints        


CHAPTER    XIV. 

Regional  surgery— The  head— Tumors  of  the  scalp— Absccss—Pneiimatocele— Encephalocele— 
Meningocele— Neoplasms  of  the  meninges— Hydroceiihalus- Wounds  of  the  scalp— Of  the 


319 


CONTENTS.  ix 


brain — Cerebral  localization — Surgery  of  the  face — Surgery  and  surgical  diseases  of  the 
eyelids  and  of  the  orbital  cavity  (not  including  lesions  of  the  globe) — Sebaceous  tumors — 
Hordeolum  —  Chalazion — Blepharitis — Conjunctiritis — Ophthalmia  neonatorum — Oonor- 
rhceal  ophthalmia — Symblepharon — Ectropion — Entropion — Ptosis — Trichiasis — Eiiiphora 
— Neoplasms  of  the  orbital  cavity — Surgery  of  the  ear — The  nose — Epistaxis — Foreign 
bodies — Rhinolites — Neoplasms — Deviation  of  the  septum — Plastic  surgery  of  the  nose, 
lips,  and  cheeks — Lupus — Ilare-Iip — Cleft-palate — Cheiloplasty — Parotid  gland  and  duct 
— Submaxillary  gland — The  jaws — Removal  of  tumors  from  the  antrum  of  Highmore — 
The  teeth — Palate — Staphylorraphy — Tongue  and  buccal  cavity — Tonsils   ....  373 


CHAPTER    XV. 

The  neck — Wounds — Abscess — Tumors — Thyroid  body — Thyrotomy — Laryngotomy — Laryn- 
go-traeheotomy — Tracheotomy — Exsection  of  the  larynx — Intubation  of  the  larynx — 
Foreign  bodies  in  the  air-passages — Neoplasms  of  the  larynx  and  trachea — Pharynx — 
(Esophagus — Foreign  bodies — CEsophagotomy  for  stricture — New  formations — OEsopha- 
gectomy • 444 


CHAPTER    XVI. 

Thorax — Mammary  gland — Mastitis — Abscess — Hypertrophy — Tumors — Exsection  of  the  clavi- 
cle— Empyema — Wounds  of  the  chest 465 


CHAPTER    XVII. 

Abdomen — Stomach  —  Gastrostomy — pyloreetomy — Gastrectomy — Gastro  -  pyloreotomy — Gas- 
tro-enterostomy — Duodenum — Obstruction  of  the  alimentary  canal — Impaction  of  fecal 
matter — Foreign  bodies — Intussusception — Volvulus — Constriction  by  bands — Adhesions 
— Omental  and  mesenteric  slits — Diverticula — Neoplasms — Stricture — True  hernia — Ab- 
dominal section  for  intestinal  occlusion — Exsection  of  the  intestine — Fecal  fistula — En- 
terocele — Epiplocele — Inguinal  hernia — Congenital — Infantile — Femoral,  umbilical,  ven- 
tral, diaphragmatic,  gluteal,  obturator,  lumbar,  and  v.aginal  hernia — Colostomy — Peritoni- 
tis— Alidominal  abscess — Liver — Hepatic  abscess — Hydatid  cyst — Spleen — Wounds  of  the 
abdomen — Intestinal  suture 47 


CHAPTER  XVIII. 

Rectum  and  anus — ."Vtresia  ani  et  recti — Pruritus  ani— Foreign  bodies — Fistula;  in  ano  at 
recto — Fissure — Ulcers — Stricture— Neoplasms  of  the  rectum  and  anus — Neuralgia — Pro- 
lapsus— Haemorrhoids 528 


CHAPTER   XI.X. 

Genito-urinary  organs — Kidneys — Suppression  of  urine — Nephrotomy  and  nephrectomy — Ure- 
ters— Bladder — Wounds — 1  ufilt ration  of  urine — Cystitis — Paralysis — Incontinence — Neo- 
plasms— The  urine — Stone — Lithotrity — Lithotomy — Prostate  body — Spermatorrhoea — 
Asperraatism  —  Urethra —  Gonorrhoea — Balanitis — Posthitis —  Gonorrhavil  rheumat  is:n — 
Gleet — Stricture — Mcatoniy — Internal  urethrotomy — Dilatation — Jlodilied  inti'rnal  ure- 
throtomy— External  urethrotomy  or  perineal  section — Sounds — Foreign  bodies  in  the  ure- 
thra— Congenital  and  acquired  malformations — Neojilasms — Cancer  of  the  penis — .Vnipu- 
tation — Humphrey's  operation — Phimosis — Circumcision — Dilatation  of  the  prepuce — 
Ulcers  of  the  penis — Syphilis — Scrotum — Hydrocele — Varicocele — Epididymis — Testicle 
— Hysterotomy — Hysterectomy — Ovariotomy 555 


X  CONTENTS. 

CHAPTEK  XX. 

PAGfU 

Deformities  of  tlie  spine — Torticollis — Lateral  iiiul  rotarv-lateriil  curvature — Scoliosis — Cypho- 
sis — Spoiiilylitis — Spina  bifitla — Deformities  of  the  lower  extremity — Preternatural  mo- 
bility of  the  hip — Sub-troehantcric  osteotomy — lienu  valgum — (ienu  varum — Talipes — 
Polydactylus — Syndaetylus — Hallux  valgus — Ilaiumer-toes — In-growing  Nail — Deformi- 
ties of  the  iipper  extremity — Club-hand — Weli-(inger — Snap-finger 691 


CHAPTER  XXI. 

Tumors  — Carcinoma  —  Epithelioma  —  Lymphadenoma  —  Sarcoma  —  Papilloma  —  Adinoma — 
Cysts — Lipoma — Fibroma — Myxoma — Myoma — Neuroma — Angioma — Lymphangioma — 
Chondroma — Osteoma 'I4ii 


A 


TEXT-BOOK    ON    SURGERY. 


CHAPTER  I. 

SURGICAL  DRESSINGS. 


The  materials  used  in  the  performance  of  a  surgical  operation,  and  in 
its  after-treatment,  form  such  an  important  part  of  the  surgeon's  outfit 
that  I  have  determined  to  devote  the  initial  chapter  of  this  book  to  a 
description  of  the  methods  of  preparing  and  preserving  the  apparatus 
needed  for  dressing  wounds  in  the  antiseptic  practice  of  to-day. 

This  practice,  which  embodies  the  great  principles  of  cleanliness  and 
carefulness  in  surgery,  is  nt)w  so  well  established  among  the  best  sur- 
geons in  America  and  Europe  that  any  argument  in  its  favor,  as  compared 
with  the  methods  of  one  or  two  decades  ago,  I  consider  to  be  wholly 
unnecessary. 

Ligatures  and  Sutures. — Catgut,  silk,  silk-worm  gut,  and  silver  wii'e 
will  meet  every  requirement  in  tying  vessels  and  closing  wounds.  Catgut 
has  practically  superseded  all  other  substances  as  a  ligature.  The  con- 
ditions which  would  justify  the  application  of  a  silk,  metal,  or  any  non- 
absorbable ligature  to  an  artery  are  rarely  present.  Strings  or  cords 
made  from  animal  tissues,  as  buckskin,  ox-aorta,  nerve,  tendon,  and 
whalebone,  known  under  the  general  name  of  "broad  ligatures,"  have 
been  successfully  employed  in  the  occlusion  of  the  larger  vessels,  but 
their  use  is  limited  in  comparison  with  that  of  the  violin-strings,  which 
are  easily  obtained,  prepared  and  preserved,  and  are,  moreover,  cheap. 

In  the  preparation  of  catgut  select  four  sizes  of  the  best  quality  of 
violin- strings  in  about  this  proportion :  one  dozen  each  of  the  E  and  A 
strings,  six  D  strings,  and  two  or  three  harp-strings  about  twice  as  large 
as  that  of  D,  violin.  The  smaller  sizes  are  most  generally  needed  for  the 
smaller  vessels  and  bleeding  points,  the  D  string  is  best  adapted  to  ves- 
sels as  large  as  the  radials,  idnars,  or  tibials,  while  the  larger  or  harp- 
strings  should  be  iised  upon  the  iliacs,  subclavians,  common  carotids, 
and  femorals. 

Preparation. — Cut  and  remove  the  small  red  threads  which  are  tied 
around  each  bunch,  and  place  the  catgut  in  a  glass  bottle  or  jar  which 
1 


A  TEXT-BOOK   ON   SURGERY. 


Fin.  1. 


contains  enough  pure  oil  of  juniper-ben- ies  to  completely  cover  tlieiii. 

The  vessel  should  be  tightly  corked  to  prevent  evaporation.     AVithin 

twenty-four  hours  the  niatt-rial  is  safely  aseptic,  and  will  remain  so  in- 

deMnitely  ii'  kei)t  iniiuersed  in  the  Huid.     Tlie  strength 

^v  of  the  gut  is  not  impaired,  while  its  firmness  is  in- 

^L^  creased  by  the  oil. 

^™^  If  oil  of  juiiipet  can  not  be  obtained,  95  per  cent 

alcohol  is  etjually  aseptic,  and  may  be  used  instead. 
Alcohol,  however,  softens  the  strings  more  than  juni- 
per, and  is  not  to  be  preferred.  Fig.  1  represents  a 
convenient  apparatus  for  holding  tliese  ligatures.  It 
consists  of  a  glass  jar  or  bottle,  with  a  wide  mouth,  in 
wliich  a  perforated  cork  is  fitted.  Within  the  bottle  are 
several  glass  spools  upon  which  the  ligatures  have  been 
wound.  The  ends  i)roject  through  the  perforation  in 
the  cork,  and  are  held  here  by  a  small(>i-  cork  fitted 
into  the  perforation.  Upon  removing  the 
smaller  plug,  the  threads  may  be  drawn 
out  and  cut  off  as  required.  Another 
vessel  is  pictured  in  Pig.  2.  In  this  the  ligatures  are 
wound  around  a  central  shaft,  wliicli  is  ])ulled  completely 
out  of  the  bottle  when  the  threads  aiv  mi'ded. 

Maceweu  has  introduced  a  rlnoii/ic-dcid  catgut  liga- 
ture, wliich  resists  absorption  much  longer  than  juniper 
or  alcohol  gut.  His  method  is:  chromic  acid  one  part, 
water  live  parts  (by  weight).  To  one  part  of  this  solution 
add  twenty  parts  of  glycerin,  and  allow  the  violin-strings 
to  remain  immersed  for  seven  or  eight  months.  They  are 
then  preserved  in  carbolic  acid  one  part,  to  glycerin  ten 
(1  to  10).  Thus  prepared,  catgut  will  resist  absorption  from  twenty  to 
sixty  days. 

8ilk  is  invalualde  for  sutures.  It  is  not  to  be  used  for  ligatures,  ex- 
cept in  certain  operations  within  the  abdominal  cavity,  or  in  wounds 
which  are  to  be  treated  by  the  open  method.  This  material  should  be 
selected  of  all  sizes.  I  prefer  the  twisted  to  the  braided  threads,  although 
the  latter  is  less  likely  to  become  tangled.  The  very  finest  black  iron- 
dyed  silk  is  needed  in  the  plastic  surgery  of  the  neck  and  face,  in  the 
white  individual.  "White  sutures  often  became  so  discolored  that  they 
are  with  difficulty  found  when  the  time  for  their  removal  arrives.  The 
larger  silk  sutures,  such  as  those  employed  in  tying  hemorrhoidal  mass- 
es, should  be  so  strong  that  any  ordinary  force  can  not  break  them.  All 
silk  threads  should  be  kept  dry,  and  well  wrapped  in  protective  or  oil- 
silk,  or  corked  in  jars.  A  half-hour  before  using  them  they  should  be 
soaked  in  a  5-per-cent  solution  of  carbolic  acid. 

Silk-worm  gut  comes  in  bristles,  or  stiff  threads,  about  ten  inches  in 
length.  It  may  be  used  as  a  suture  in  any  part  of  the  economy,  but  it  is 
essential  only  in  the  operation  for  cleft  i)alate.  It  is  not  absorbable,  is 
very  strong,  ties  easily,  and  does  not  slip.     It  should  be  kept  in  an  ordi- 


Fu; 


SURGICAL  DRESSINGS. 


nary  dry  box,  and  need  not  be  rendered  aseptic  for  operations  on  the 
palate. 

Silver  loire  is  invaluable  as  a  suture-material.  Beyond  the  operations 
upon  the  genito-urinary  oi'gans  of  the  female,  where  it  is  indispensable, 
it  is  preferable  to  silk  in  many  wounds  of  other  portions 
of  the  body.  The  sizes  most  required  range  from  Nos.  24  to 
31,  inclusive.  A  most  convenient,  way  of  carrying  silver  for 
immediate  use  is  to  cut  it  in  pieces  about  ten  inches  in 
length,  and  place  it  in  a  metal  cylinder  (Fig.  3),  which  is 
divided  into  three  or  four  compartments,  and  closed  by  a 
screw-top.  Or  the  wire  loops  may  be  wrapjDed  in  jji'otective 
or  blotting-paper,  and  thus  kept  free  from  moisture  in  order 
to  prevent  rust.  They  are  rendered  aseptic  by  immersion  in 
1  to  20  carbolic  acid  one  half-hour  before  using  them. 

Solutions. — For  ii'rigating  wounds,  submerging  instru- 
ments, and  disinfecting  in  general,  solutions  of  corrosive  sub- 
limate and  carbolic  acid  are  necessary,  and  pure  alcohol,  iodo- 
form, and  chloride-of-zinc  solutions  may  at  times  be  used. 

Koch  has  demonstrated  that,  as  a  germ-killer,  corrosive 
sublimate  excels  all  known  agents.  The  sublimate  solutions 
vary  in  the  proportion  of  one  part  of  the  bichloride  to  five 
hundred  parts  of  distilled  water  by  weight,  or  1  to  500,  1  to 
1,000,  1  to  2,000,  1  to  3,000  for  use  outside  of  the  gi-eat  cavi- 
ties, and  1  to  8,000,  1  to  15,000,  and  1  to  20,000  within  the 
cavities. 

The  sublimate  solutions  are  only  used  for  irrigation  and 
for  disinfecting  the  hands,  sponges,  and  gauze.  All  instru- 
ments are  submerged  in  carbolic-acid  solutions  or  in  alcohol. 

The  stronger  solutions,  1  to  500  and  1  to  1,000,  are  rarely 
employed  in  irrigation,  and  then  only  when  the  jjart  exposed 
has  been  made  bloodless  by  the  Esmarch  bandage.  Even 
when  thus  employed  for  the  disinfection  of  an  abscess  cav- 
ity, ulcer,  or  sinus,  the  excess  of  sublimate  should  be  imme- 
diately washed  away  by  flooding  the  part  with  the  1  to  3,000 
solution.  In  any  ordinary  operation  no  stronger  sublimate 
than  1  to  3,000  will  be  required  ;  a  1  to  10,000  solution  may 
be  used  in  the  peritoneal  or  thoracic  cavity  where  the  con- 
ditions are  such  that  the  fkiid  may  run  out  or  be  removed  at 
once  by  sponges.  I  have  filled  the  entire  abdominal  cavity  i"""-  3. 
with  warm  sublimate,  1  to  18,000,  mopping  it  out  with 
sponges,  and  repeating  this  procedure  three  times  without  any  bad 
symptom  resulting. 

For  convenience,  any  required  solution  may  be  made  from  the  follow- 
ing :  Corrosive  sublimate,  gr.  xxx  ;  water  and  glycerin,  each,  §  ss.  Some 
add  to  this  about  gr.  x  of  table-salt.  One  teaspoonful  of  this  solution 
added  to  a  pint  of  water  approximates  1  to  2,000.  "Water  containing  lime 
should  not  be  used.  Tablets  of  corrosive  sublimate  are  now  manufact- 
ured, and  are  very  convenient  for  transportation.     Each  tablet  contains 


A   TEXT-BOOK   ON   SURGERY. 


Flu.  4. — Weir's  antiseptic  spray-machino. 


enougli  sublimate  to  make,  when  dissolved  in  a  pint  of  water,  a  1  to 
1,000  solution.  It  is  best  to  make  fresh  solutions  when  needed,  for,  un- 
less kept  tightly  corked  and  away  from  light,  they  deteriorate  in  value. 

CarbuUc  acid  (1  to  20,  or  a  5-per-cent  solution)  is  employed  for  the 
cleansing  and  submersion  of  all  instruments  used  in  a  surgical  ojiera- 

tion.  It  is  not  used  in 
irrigation  on  account  of 
its  irritating  properties. 
The  steam  and  carbolic 
spray  so  much  in  vogue 
a  few  years  since  is  now 
only  used  to  lay  the 
dust,  or  as  an  aid  to- 
ward the  more  thorough 
cleansing  of  operating- 
rooms  and  wards  which 
are  especially  exposed 
to  infection.  The  spray- 
machine  (Fig.  4)  is  start- 
ed one  half-hour  before 
the  operation  is  to  commence,  and  is  allowed  to  run  until  that  time.  The 
strength  of  the  solution  in  the  bottle  is  1  to  20. 

As  ordinarily  sold,  carbolic  acid  is  dissolved  in  alcohol,  and  is  about 
95  per  cent  strong.  In  this  condition  an  ounce  by  measurement  is  an 
ounce  by  weight.  To  this  quantity  add  glycerin  3  j,  and  water  3  xix, 
which  will  make  a  1  to  20,  or  5-per-cent  solution.  All  instruments  are 
immersed  in  this  solution  a  half-hour  ])efore  the  operation,  except  the 
blades  of  the  knives,  which  should  be  dipped  in  only  a  minute  or  two 
before  being  nsed. 

Pure  alcohol  is  also  nsed  for  this  purpose  by  some  operators  who  dis- 
like the  benumbing  effects  of  the  acid. 

loduform,  one  part  dissolved  in  seven  parts  of  ether,  is  used  at  times 
to  wash  the  parts  where  an  operative  wound  is  to  be  made.  It  is  not  an 
uncommon  practice  with  some  of  the  German  surgeons  to  immerse  all  the 
ligatures  and  suture-material  in  this  solution  for  about  twenty  minutes 
before  the  operation  is  begun. 

Chloride-of-zlnc  solution  in  water  (1  to  12,  about  8  per  cent)  may  be 
used  to  wash  out  ulcers  or  old  sinuses  which  ere  in  the  neighborhood  of, 
or  communicate  with,  the  wound  of  operation.  This  and  the  iodoform 
solution  are  not,  however,  essential,  and  are  now  rarely  employed. 

Irrigators. — A  rubber  bag,  capable  of  holding  two  quarts  of  solution, 
with  extra  long  tubing  attached,  makes  a  convenient  irrigator  for  use  and 
transportation.  The  ordinary  fountain-syringe,  represented  in  Fig.  5,  is 
commonly  used.  The  nozzles  should  be  of  smooth  glass,  sufficiently 
heavy  to  resist  breakage,  about  three  or  four  inches  in  length,  not  more 
than  a  quarter  of  an  inch  in  gross  diameter,  slightly  pointed,  and  with  a 
lumen  of  one  eighth  of  an  inch.  Sublimate  solution  should  not  l)e  allowed 
to  remain  in  contact  with  rubber  for  any  considerable  time  on  account  of 


SURGICAL  DRESSINGS. 


its  con-osive  action.     When  an  operation  or  dressing  is  completed,  after 
the  sublimate  escapes,  pure  water  should  be  run  through  the  irrigator. 

A  good  emergency  irrigator  is  shown  in 
Pig.  6.  It  is  made  by  placing  a  perforated 
cork  in  an  ordinary  wine-bottle,  fitting  a  piece 
of  glass  tube,  or  cane,  or  goose-quill  into  the 
perforation  to  which  the  rubber  hose  is  at- 
tached.    The  bottom  of  the  bottle  is  broken 


Fig.  6.— (Esmaroli.) 


Fi.i.  5. 


in,  and  a  string  netting,  thrown  around  for 
susj)ension,  comjjletes  the  apparatus.  If  there 
is  no  stop-spring  to  shut  off  tlie  flow,  it  may 
be  readily  aiTested  by  placing  the  nozzle  in 
the  upper  end  of  the  bottle.  The  assistant 
who  attends  to  the  irrigator  can  always  regu- 
late the  flow  by  slight  pressure  of  the  tube  between  the  thuml:)  and  finger, 
just  where  the  nozzle  is  attached.  Tin  or  brass  vessels  may  also  be  em- 
ployed, but  the  corrosive  action  of  the  mercury  soon  destroys  the  metal. 

When  no  irrigator  can  be  had,  the  sublimate  solution  may  be  poured 
on  from  a  i^itcher  or  cup. 

For  continuous  irrigation,  as  in  an  amputation  treated  by  the  open 
method,  a  constant  dripping  may  be  secured  by  twisting  a  piece  of  muslin 
or  cotton  cloth  into  a  loose  wick-like  string,  moistening  it,  and  placing 
one  end  in  a  vessel  holding  the  solution,  while  the  other  hangs  over  the 
edge  from  a  point  where  the  fluid  ^^^ll  fall  on  the  wounded  surface 
(Fig.  7). 

Sponges. — In  selecting  sponges,  secure  those  of  softest  and  finest  text- 
ure, measuring,  when  dry,  from  one  to  two  and  three  inches  in  diameter, 
the  greater  number  spherical  in  shape,  with  a  half-dozen  flat  jneces  a 
half-inch  thick,  three  or  four  inches  wide,  and  from  six  to  ten  inches  long. 
When  purchased  in  the  rough  they  should  be  thoroughly  whipped 
until  aU  the  sand  is  removed,  and  then  washed  in  cold  or  lukewarm 


6 


A  TEXT-BOOK   ON   SURGERY. 


water.     Two  methods  may  be  employed  for  blearliing.     Tlie  simpler  way 
is  to  soak  them  for  from  six  to  eighteen  hours  in  a  mixtui'e  of  one  X'art 


Fig.  7. 


of  liquor  s(xl;e  chlorinatje  to  five  of  water,  rinse  them  in  elear  cold  water, 
and  dry  thoroughly.  A  more  complicated  but  very  efficacious  method  is 
the  following  :*  Place  the  sponges  in  a  solution  of  permanganate  of  po- 
tassa,  1  to  100  (about  gr.  v-  3  j  of  water\  for  one  half-hour ;  rinse  in  clear 
cold  water,  squeeze  thoroughly,  and  immerse  them  in  a  solution  of  oxalic 
acid  (1  to  50)  for  ten  minutes.  Rinse  again  in  clear  water,  leave  them 
there  for  one  hour,  and  then  dry  quickly  in  a  warm  oven.  Sponges  may 
be  kept  dry  either  in  tightly  corked  glass  or  stone  jars,  or  wrapped  up  in 
protective,  and  put  away  in  a  clean  drawer.  They  may  also  be  kept 
indefinitely  in  a  1  to  20  carbolic-acid  solution,  but  should  not  be  kept  any 
length  of  time  in  sulilimate  solution. f  When  a  sponge  has  been  once 
used  it  should  be  destroyed,  unless  the  circumstances  are  such  that  other 
and  fresh  pieces  can  not  he  obtained  for  a  succeeding  operation.  Even 
under  such  conditions,  if  tliey  have  been  brought  in  contact  with  septic 
matter,  it  should  be  imperative  to  destroy  the  sponges  and  proceed  with- 
out them,  using  clean  cloths,  or  towels,  or  borated  or  absorbent  cotton  in 
their  stead. 

To  cleanse  sponges  which  have  been  used,  wash  them  thorough- 
ly in  different  changes  of  warm  water  (not  hot),   and,   when  they  no 

*  To  Mr.  Anselo,  druggist,  of  Fourth  Avenue  and  Thirty-first  Street,  New  Yorlv,  I  am 
indebted  for  this  formula. 

t  Mr.  Charles  G.  Am  Ende,  108  Washington  Street,  noboken,  New  Jersey,  prepares  sponges 
that  are  soft,  clean,  and  very  satisfactory,  as  well  as  cheap. 


SURGICAL   DRESSINGS. 


longer  discolor  clear  water,  immerse  them  in  1  to  500  sublimate  for  one 
hour. 

In  all  operations,  sponges,  before  being  used  in  the  wound,  should  be 
dipped  in  1  to  3,000  sublimate  solution,  and  then  squeezed  as  dry  as 
possible. 

Drains. — Ruhher  tubing,  Neuber's  hone  drains,  and  twists  of  catgut 
or  horse-liair,  are  chiefly  to  be  relied  upon  in  draining  wounds.  Rubber 
is  most  generally  useful.  The  softest  tubing  should  be  selected,  of  vari- 
ous sizes,  from  that  which  has  a  lumen  of  one  half-inch  in  diameter  down 
to  one  sixteenth.  Before  it  is  inserted  it  should  be  bent  over  the  flnger, 
and  with  a  j)air  of  curved  scissors  clipped  full  of  holes  about  a  half-inch 
apart,  as  seen  in  Fig.  8.  Rubber  drains  shoidd  be  kept  dry  in  clean  jars, 
from  which  they  are  taken  and  placed  in  1  to  20  carbolic  acid  solution 
when  the  operation  for  which  they  are  needed  is  begun.  When  a  wound 
is  to  be  dressed  only  once — the  "permanent  dressing" — absorbable  ani- 
mal drains  should  be  inserted.  For  this  purpose  Neuber's  bone  tubes 
(Fig.  9)  are  preferable.  They  are  made  from 
the  bones  of  young  and  healthy  animals.  The 
crude  bone  is  cut  of  j^roper  length  and  size, 
bored  out,  turned  on  a  lathe  round  and  smooth, 
and  perforated  laterally.  Immersion  in  33- 
per-cent  muriatic  acid  for  twelve  hours  com- 
pletely decalcifies  them,  after  which  they  are 
kept  (as  recommended  by  the  inventor)  in  1 
to  20  carbolic-acid  solution,  frequently  re- 
newed. I  prefer  to  keep  them  in  alcohol,  95 
per  cent,  or  oil  of  juniper,  which  preserves 
them  aseptic  and  hardens  them,  rendering  a 
too  rapid  absorption  less  likely.  The  tubes 
are  from  three  to  five  inches  long.  There  are 
four  sizes  :  the  caliber  of  No.  1  is  six,  No.  2  is 
five.  No.  3  is  four,  and  No.  4  three  millimetres 
in  diameter  (one  millimetre  is  approximately 
5^  of  an  inch).  The  walls  are  from  one  to  one 
and  a  half  millimetre  in  thickness. 

These  drains  can  be  prepaied  readily  from  Fig.  8. 

the  bones  of  fowls  by  scraping  the  perios- 
teum off  and  the  marrow  out,  soaking  in  muriatic  acid  (33-per-cent  solu- 
tion) as  above,  and  then  in  ether  for  a  few  hours  before  transferring  them 
to  the  alcohol.*    Bone  drains  will  be  absorbed  in  from  five  to  twenty 
days,  and  are  excellent  in  permanent  dressings. 

Catgut  or  Jiorst'-Jiair  twists  or  skeins  are  at  tunes  employed  for  drain- 
ing small  wounds,  and  are  very  satisfactory.  The  violin-strings  are 
twisted  into  a  bunch,  as  shown  in  Fig.  10,  and  laid  in  the  wound  at  vari- 

*  If  the  bones  used  are  from  fowls  wliich  have  been  cooked,  Macewen  reponimocds  tliat 
the  hydrochloric-acid  solution  should  he  one  to  five  of  water,  and  that  the  tube,  when  in- 
serted into  the  wound,  should  be  threaded  with  horse-hair  to  prevent  collapse  from  pressure, 
and  to  facilitate  the  removal  of  clots  without  taking'  out  the  tube  and  irritating  the  wound. 


Fio.  9.      Fig.  10. 


8  A  TEXT-BOOK   ON  SURGERY. 

oils  points,  so  as  to  project  at  the  lower  angles  or  in  such  i)ositions  as 
will  secure  the  most  perfect  drainage.  The  hair  is  taken  from  the  mane 
or  tail,  washed  clean,  and  immersed  for  twenty-four  hours  in  oil  of 
juniper.     It  is  twisted  iu  the  same  manner  as  the  catgut. 

Protective. — Thin  rubber  tissue,  oil-silk,  or  Mackintosh  cloth,  may 
be  used  to  protect  the  part  from  atmospli(>ric  clianges,  and  to  ])r('vent 
the  evaporation  and  volatilization  of  the  antiseptic  agents.  The  former 
is  preferable,  and  the  oil-sOk  is  next  in  order.  Rubber  tissue  must  be 
kept  in  a  cool,  dry  spot,  and  should  be  dipped  in  1  to  3,000  sublimate 
before  it  is  applied. 

Gauze. — Ordinary  cotton  muslin  f)f  light  texture,  commonly  known 
as  cheese-cloth,  impregnated  with  corrosive  sublimate  or  iodoform,  is 
widely  used  as  antiseptic  gauze. 

Carbolized  gauze  has  passed  out  of  use. 

To  make  sublimate  gauze  proceed  as  follows :  Cut  a  bolt  of  cheese- 
cloth into  pieces  a  yard  long,  and  place  in  boiling  water  for  eight  hours. 
Then  rinse  thoroughly  in  cold  water,  and  bleach  in  liquor  sodse  chlorinatae 
(one  part  to  five  of  water)  for  twenty-four  hours.  Rinse  again  in  clear 
water,  and  leave  the  cloth  in  a  tightly  covered  jar  or  tank  of  1  to  500 
sublimate  indefinitely.  When  the  gauze  is  about  to  be  used,  squeeze  the 
water  out  of  it  and  wet  it  in  fresh  1  to  3,000  solution,  and  again  squeeze 
it  until  it  is  only  fairly  moistened,  not  dripping,  with  the  solution.  Am 
Ende's  sublimate  pink  gauze  is  an  excellent  pi-eparation.  It  is  stained 
with  eosine,  which  is  a  color-test  upon  the  purity  of  the  gauze,  for,  if  the 
mercury  is  decomposed  or  volatilized,  the  eosine  goes  with  it  and  the 
gauze  is  left  white. 

lodoformized  gauze  is  made  by  moistening  the  washed  cheese-cloth 
in  1  to  3,000  sublimate,  sprinkling  it  with  powdered  iodofomi  from  a 
pepper-box,  and  then  working  the  powder  into  the  meshes  of  the  cloth 
until  it  is  a  golden-yellow  color.  It  should  be  made  fresh,  although  it 
may  be  preserved  for  one  or  two  weeks  in  tight  glass  jars,  wTapped  in 
red  or  blue  paper  to  prevent  the  decomposition  of  light. 

Borated  absorbent  cotton  is  now  almost  indispensable  in  surgical 
practice.  It  is  used  not  only  to  protect  the  part  and  to  exercise  com- 
pression, but,  for  purposes  of  cleansing  and  dressing  wounds,  it  has  en- 
tirely superseded  sponges,  and  is  not  only  cheaper,  but  preferable  in  every 
respect.  It  is  so  difficult  to  prepare,  however,  that  the  practitioner  is 
almost  compelled  to  patronize  the  manufacturer.  When  an  emergency 
demands  it,  ordinary  ginned  cotton  of  clean  fiber  may  be  bleached  and 
softened  by  treating  it  in  the  same  way  as  given  for  the  cheese-cloth. 
It  can  be  charged  with  boracic  acid  by  immersing  it  in  a  solution  con- 
taining gr.  XV  to  3  j  of  water.  It  is  then  dried  and  wrapped  in  protect- 
ive until  needed  for  use. 

Well-prepared  borated  cotton  is,  next  to  gauze,  the  most  suitable  ab- 
sorbent of  discharges  from  wounds.  Beyond  these  two  substances  noth- 
ing is  really  needed.  Pads  or  bags  of  peat,  sawdust,  jute,  wood-wool, 
etc.,  are  practically  useless. 


CHAPTER  11. 

BAJfDAGI^'^G. 

Baxdages  are  employed  in  surgical  practice  to  retain  dressings  in 
position,  to  secure  compression  and  supi^ort  to  any  portion  of  the  body, 
to  maintain  any  required  degree  of  immobility,  and  to  render  an  extremity 
partially  or  completely  bloodless. 

They  are  made  of  cotton  muslin  of  various  degrees  of  fineness,  crino- 
line, woolen  goods,  and  India  rubber.  Cotton  bandages  are  most  gener- 
ally employed,  but,  on  account  of  the  greater  elasticity  of  flannel,  these 
are  preferable  for  certain  special  di-essings.  Ci'inoUne  is  only  used  for 
plaster-of-Paris  bandages.  Martin's  rubber  bandage  and  Esma'rch's  blood- 
less tourniquet  are  very  useful  in  maintaining  the  finn  compression  of  a 
part,  either  as  a  means  of  support  or  of  emptying  the  vessels. 

The  muslin  should  be  soft,  not  starched,  and  of  two  kinds — a  fairly 
heavy  quality,  and  the  light  cheese-cloth.  Both  should  be  cut  in  pieces 
from  eight  to  ten  yards  in  length.  The  fonner  can  be  torn ;  the  latter 
must  be  cut.  The  selvage  edge  is  removed,  and  the  cloth  divided  into 
strips  varying  in  width  from  four,  three,  two  and  a  half,  and  two  inches, 
with  some  one  inch  or  less  in  width.  For  the  chest  and  alxlomen  the 
wide  bandages  are  needed,  the  two-  and  three-inch  strips  for  the  arms, 
legs,  head,  and  neck,  and  the  narrow  strips  for  the  hands  and  tingers. 
All  the  loose  ravelings  along  the  edges  should  be  pulled  off,  and  the 
bandages  made  into  compact,  smooth  rollers. 

Bandages  may  be  rolled  by  hand,  yet  it  is  a  tedious  and  tiresome 
business,  and  an  utter  waste  of  time,  when  the  work  can  be  better  and 
more  rapidly  done  by  machinery. 
In  Fig.  11  is  pictured  a  bandage- 
roller,  simple  in  construction  and 
cheap.  It  should  be  fastened  to 
the  edge  of  a  solid  table  by  screws 
or  movable  clamps.  The  end  of  the 
strip  to  be  wound  is  passed  in  and 
out  over  the  four  bars  at  the  base 
and  apex  of  the  machine,  and  then 
around  the  sliaft,  so  that  one  edge 
of  the  bandage  touches  the  end  of  the  u])right.  As  the  crank  is  turned, 
the  strip  is  held  tightly,  and.  as  it  runs  over  the  rods,  wrinkling  or  fold- 
ing is  pi'evented.     A  home-made  apjiaratus  may  be  constructed  as  fol- 


10 


A  TEXT-BOOK   ON   SURGERY. 


lows  :  Tiike  a  cigar-box,  remove  the  top  and  one  end,  bore  a  liole  in  each 
side-piece  near  the  open  end,  and  through  these  pass  a  piece  of  telegraph- 
wire  bent  in  the  shape  of  a  windhiss  and  crank.  Wires  may  be  run 
through  at  other  i)oiuts  to  serve  tlie  same  purpose  as  tlie  four  rods  in 
the  other  machine. 

In  making  plaster-of-Paris  l>andages,  these  same  machines  may  be  em- 
ployed, but  the  crinoline  must  be  loosely  rolled,  and  tlie  powdered  plaster 
worked  in  with  the  hands  so  well  and  thoroughly  that  the  meshes  of  the 
cloth  can  not  be  seen.  Considerable  experience  is  required  to  prepare  a 
good  plaster  bandage,  and  a  poor  one  will  spoil  a  dressing.  Plaster  band- 
ages should  be  made  from  fresh  gypsum  on  the  day  they  are  to  be  ap- 
plied. Cotton  and  flannel  bandages  should  be  kept  in  a  chest  or  closet 
away  from  dust  and  moisture. 

Ilethods  of  applying  Bandages. — The  various  portions  of  the  body 
may  be  bandaged  by  the  simple  spiral,  reverse  spiral,  s imple  Jtgure-of-H, 
and  the  figure-of-S  reverse. 

The  simple  spiral  tiirn  is  most  useful  in  bandaging  those  parts  of  the 
body  where  there  is  no  sudden  increase  in  the  diameter  and  volume  of  the 
part.     It  is  impracticable  xmder  other  circumstances. 

Hold  the  bandage  .in  the  hand  most  convenient,  with  the  back  of  the 
roller  toward  the  limb  (see  Fig.  12) ;  with  the  unoccupied  hand  take  the 


Fig.  12, 


Fig.  13. 


free  end  of  the  liandage,  lay  and  hold  it  upon  the  inner  border  of  the 
limb,  and  carry  the  turn  by  the  front  to  the  outer  side  of  the  part  to  be 
bandaged. 

Having  cariied  the  roller  twice  ai'ound  the  part  to  secure  it,  ascend  the 
limb  spirally,  leaving  about  one  thii-d  of  each  turn  uncovered  by  the  last. 


BANDAGING. 


11 


The  recerse-spiral  turn  (Fig.  13)  is  applied  as  follows : 

Taking  tlie  left  arm  to  be  bandaged,  hold  the  roller  in  tlie  right  hand, 
with  its  convexity  toward  the  limb,  and  carry  it  from  the  inner  or  ulnar 
border,  by  the  front,  to  the  outer  or  radial  border,  and  thus  around  tho 
arm  by  two  circular  turns  to  secure  the  roller.  Then,  having  carried  the 
l:)andage  to  the  outer  side,  ascending  the  limb  gradually,  lay  the  thumb 
of  the  left  hand  upon  the  lower  edge  of  the  bandage,  press  it  fii'mly 
against  the  limb  to  prevent  slipping,  loosen  the  roller  considerably  in  the 
right  hand,  at  the  same  time  turning  it  one-half  turn  toward  the  operator. 
This  process  is  to  be  repeated  as  often  as  necessary,  keeping  the  reverses 
well  upon  the  outer  border  and  anterior  aspect  of  the  extremity. 

Th  e  Simple.  Fig  ii  re  -  of-  8 
Turn. — After  the  bandage  is  se- 
cured, as  heretofore  described, 
ascend  the  limb  shaq^ly,  from 
the  inner  to  the  outer  border, 
so  that  at  this  outer  border  the 
lower  edge  of  the  roller  shall  be 
several  inches  above  the  start- 
ing-point. Carry  the  roller  di- 
rectly across  and  behind  the 
limb  to  the  same  point  on  the 
opposite  side ;  then  obliquely 
downward  in  front,  crossing  the 
ascending  turn  at  a  right  angle. 
AVhen  the  outer  border  is  again 
reached,  carry  the  roller  behind 
and  directly  across  the  limb  to 
the  starting-point  (see  Fig.  14). 

The  Figure- of -8  Reverse. — 
Commence  exactly  as  for  the 
simple  figure-of-8  until  the  band- 
age has  passed  across  the  pos- 
terior aspect  of  the  liml),  and 
is  about  to  descend  obliquely 

along  the  inner  aspect  to  the  front.  With  the  index-finger  of  the  unoc- 
cupied hand  hold  the  lower  edge  of  the  bandage  tightly  against  the  part, 
while  the  roller  is  .slackened  and  turned  half  over  in  a  direclion  away 
from  the  limb.  This  reverse  in  the  figure-of-8  may  also  be  made  ante- 
riorly, and,  when  the  conformation  of  the  part  demands  it,  may  be  made 
both  anteriorly  and  posteriorly. 

Of  these  four  methods,  the  simple  spiral  is  more  readily  applied. 
When  the  diameter  of  the  extremity  increases  rapidly  it  will  not  suffice, 
since  it  grasijs  the  part  at  the  upper  edge  of  the  roller  while  the  lower 
stands  out  free  and  loose. 

For  all  purposes  the  spiral  reverse  is  more  generally  useful.  In 
competent  hands  it  can  be  applied  to  all  portions  of  the  body  exce])t 
where  the  members  join  the  trunk,  when  it  nuxst  give  place  to  the  simple 


Fin.  14. — The  fi<jiire-oi'-8  method. 


12 


A  TEXT-BOOK  ON   SURGERY. 


fignre-ofS  turn.  Thus,  the  spica  at  the  groin  and  shoulder,  the  occiput 
and  chin  dressings,  and  the  neck  and  shoulder  bandages,  must  describe 
this  shape.  Tlie  ftgure-of-S  rercrse  is  of  great  use  in  getting  over  the  calf 
of  the  leg  in  very  muscular  subjects,  where  not  infrequently  all  the  other 
methods  will  fail  to  hold. 

The  important  rule  in  bandaging  is  to  equalize  the  prestsi/re  from 
periphery  to  center.  The  circumstances  of  the  case  will  determine  the 
degree  of  compression.  It  requires  a  great  deal  of  study  and  practice  to 
become  expert  in  applying  dressings.  One  should  thoroughly  familiarize 
one's  self  with  each  of  the  methods,  for  not  infrequently  a  part  to  be 
dressed  will  require  a  combination  of  several  methods.  The  question  of 
how  tight  to  apply  the  bandage  may  in  part  be  left  to  the  sense  of  the 
])atient  when  an  anaesthetic  is  not  emjiloyed.  After  an  extensive  oi)era- 
tion,  in  which  Esmarch's  bandage  has  been  applied,  a  very  considerable 
degree  of  compression  is  often  requii-ed  to  pi-event  the  oozing  which 
otherwise  would  follow  the  use  of  this  tourniquet.  No  amount  of  de- 
scription will  impart  this  sense  to  the  inquirer ;  it  can  only  come  from 
personal  experience.  One  precaution  is  imperative  :  the  tips  of  the  lin- 
gers or  toes  of  the  extremity  bandaged  must  always  be  left  open  for 
observation,  for  if  strangulation  is  threatened  it  will  always  be  earliest 
indicated  here.     A  watch  should  be  set  on  every  case  where  there  is 

ground  for  anxiety,  with  direc- 
tions to  slit  the  dressing  with  the 
appearance  of  any  symptom  of 
sti'angulation. 

Special  Bandar/es — The  Hand 
and  Fingers  by  the  First  Method 
(Fig.  15).^Take  a  rfiller  l)etween 
three  fourths  and  one  inch  in 
width,  and  ten  yards  in  length. 
Let  the  hand  to  be  bandaged  be 
pronated,  and  commence  by  tak- 
ing two  or  three  turns  of  the  roller 
around  the  carpus,  going  from  the 
radial  over  the  back  of  the  wrist 
to  the  ulnar  side.  Having  in  this 
manner  secured  the  roller,  cany  it 
fi-om  the  radial  side  of  the  wrist 
obliquely  across  the  dorsum  of  the 
hand  to  the  ulnar  border  of  the 
root  of  the  little  finger,  then  spi- 
rally around  the  little  finger  two 
turns  to  its  extremity.  Next,  re- 
turn by  careful  si:)iral  turns,  or  a 
spiral  reverse,  if  necessary,  to  the 
root  of  the  finger,  covering  it  equal- 
ly and  nicely.  From  the  radial  border  of  the  base  of  the  finger  the  band- 
age is  carried  over  the  back  of  the  hand  to  the  ulnar  side  of  the  carpus, 


Fig.  15. — Hand-,  thnmh-,  and  fin^er-bandase.    (The 
author's  modification  of  the  old  method.) 


BANDAGING. 


13 


then  under  the  wrist,  by  the  front,  to  the  radial  side,  and  again  over  the 
dorsum  of  the  hand  around  to  the  ulnar  side  of  the  same  finger,  repeat- 
ing the  figure-of-8,  as  before.  Two  turns  are  then  thrown  around  the 
wrist  to  secure  the  former  bandage,  and  the  roller  is  carried  in  the  same 
manner  to  the  remaining  fingers. 

When  the  index-finger  is  reached,  on  account  of  the  great  space  be- 
tween its  root  and  the  thumb,  it  is  advisable  to  make  four  or  five  exti^a 
figure-of-8  turns  around  its  base,  carrying  the  bandage  a  little  lower  with 
each  successive  layer  toward  the  thumb. 

Having  reached  the  thuml),  the  roller  is  carried  spirally  to  its  ex- 
tremity, as  in  the  other  fingers,  but  in  returning,  when  the  last,  the  in- 
terphalangeal.  joint  is  reached,  the  figure-of-8  turn  is  commenced  at  this 
point,  and  continued  until  the  ball  of  the  thumb 
is  completely  covered. 

This  method  may  be  applied  to  the  thiimb 
alone,  or  to  any  one  or  more  of  the  fingers,  when 
the  remainder  of  the  hand  does  not  need  to  be 
bandaged,  and  is  equally  efficient  in  securing 
splints  to  these  organs. 

One  objection  to  it,  and  a  very  formidable  one 
to  the  practitioner,  is  the  length  of  time  necessaiy 
to  apply  it.  A  more  rapid  and  almost  equally 
effective  way  is  the  hand-bandage  by  the  second 
method  (Fig'.  16). 

Place  pellets  of  cotton  between  the  fingers,  and 
a  fair-sized  tuft  in  the  palm  of  the  hand.  Take  a 
bandage  from  one  to  two  inches  in  AA-idth,  carry 
it  one  or  two  turns  around  the  hand  where  the 
phalanges  join  the  metacarpus,  until  it  is  secured, 
and  then  by  nicely  adjusted  figure-of-8  turns  (the 
crossings  on  the  dorsal  aspect  of  the  fingers)  cover 
the  hand  from  the  tips  of  the  fingers  back.  When 
the  bandage  reaches  the  thumb  in  the  crotch  be- 
tween it  and  the  index,  and  begins  to  roll  up,  it 
should  be  clipped  with  the  scissors  deeper  and 
deeper  along  the  edge  nearest  the  thumb  with 
each  successive  turn  until  the  cut  extends  to  the 

middle  of  the  roller.  Then  a  split  should  be  made  in  the  middle  parallel 
with  its  long  axis,  and  the  thumb  stuck  through  this  ;  the  next  split  is 
nearer  the  distal  edge,  while  vdx\\  the  succeeding  turn  it  may  be  brought 
clear  of  the  tliumb  on  its  carpal  aspect.  A  spiral,  with  or  without  the 
reverse,  will  hold  on  the  incline  from  the  thumb  to  the  carpus. 

The  Forearm,  Arm,  and  Shoulder. — From  the  carpus  to  the  elbow 
the  spiral  reverse  or  figure-of  8  will  usually  be  required,  on  account  of 
the  pyramidal  shape  of  the  part.  When  the  elbow  is  reached,  if  the 
right-angle  position  (Fig.  17)  is  determined  upon,  the  figure-of-8  around 
the  humerus  and  forearm  will  suffice  to  climb  along  tlie  elbow :  or  the 
simple  si)ii-al,  can-ied  over  the  same  ground  in  the  flexure  of  the  joint,  and 


Fio.  16. 


14 


A  TEXT-BOOK   ON   SURGERY. 


Fio.  17. 


gradually  ascending  over  the  convexity,  will  accomplish  the  same  pur- 
pose.   For  the  arm  the  spiral,  simple  or  reverse,  will  carry  the  bandage  to 

the  axill:i.  "When  the 
projection  ciiu.sed  by  the 
tendon  of  the  pectoralis 
major  is  readied,  the 
I'oller  is  carried  from  the 
inner  side  by  the  front, 
over  tlie  point  of  the 
slioulder,  around  the 
back,  and  unch'rneatli 
the  opposite  arm,  across 
the  chest  to  the  anterior 
and  outer  surface  of  the 
humerus,  then  under- 
neath the  arm,  making 
a  iigure-of-8  turn,  erne 
loop  of  which  surrounds 
the  arm,  and  the  other 
the  thorax.  Tliese  turns 
are  continued,  gradually 
ascending  until  the  root 
of  the  neck  is  reached. 
It  is  best  to  fill  the  ax- 
illa of  both  arms  with 
absorbent  cotton  to  prevent  chafing,  when  this  dressing  is  to  be  worn  for 
any  length  of  time. 

The  Toes,  Foot,  Leg,  and  TJiigTi. — The  great  toe  may  be  liandaged 
by  carrying  a  narrow  roller  spirally  around  it,  from  the  tip  to  the  meta- 
tarso-phalangeal  joint,  and 
thence  by  a  figure-of-8 
around  the  ankle.  This 
last  turn  should  be  sev- 
eral times  repeated,  in  or- 
der to  hold  the  dressing 
firmly.  It  is  customary  to 
include  all  of  the  toes  in 
the  general  foot-bandage. 
To  bandage  the  foot, 
begin  by  placing  bits  of 
absorbent  cotton  between 
the  toes.  Take  a  roller 
from  two  to  two  and  a  half 
inches  wide,  and  about 
ten  yards  long.     Lay  the 

end  of  the  bandage  parallel  with  the  axis  of  the  leg,  half-way  between 
the  two  malleoli  in  front,  and  carry  the  roller  by  the  inner  side  to  tlie 
heel,  so  that  the  middle  of  the  bandage  will  be  over  the  center  of  the 


J-'iu.  !».— Tliu  :iuthoi'8  foot-bandaLre  with  a  siiii'le  roller. 


BANDAGING. 


15 


heel's  convexity,  and  on  to  the  starting-point.  Next,  make  another  turn 
around  the  ankle,  carrying  the  posterior  edge  of  the  bandage  over  the 
center  of  the  tuni  that  has  just  preceded  it,  and  make  one  or  two  other 
turns  in  front  of  this  until  the  heel  is  completely  covered  (Fig.  18). 

The  bandage  is  then  carried  around  the  heel  in  the  same  direction,  so 
that  its  anterior  border  rests  on  the  middle  of  the  first  turn,  and  the 
roller  is  carried  from  the  fibular  side  f)f  the  heel  across  the  dorsum  of  the 
foot  to  the  tibial  side  of  the  great  toe. 
It  then  travels  under  the  bases  of  the 
toes  to  the  little  toe,  making  a  couple  of 
complete  turns  around  the  foot  at  this 
l^oint,  and,  when  the  roller  has  again 
reached  the  fibular  side  of  the  little  toe, 
it  is  made  to  cross  the  dorsum  of  the 
foot  obliquely  to  the  tibial  side  of  the 
heel,  keeping  the  lower  edge  of  the  band- 
age about  a  quarter  of  an  inch  above  the 
bottom  of  the  heel.  Repeat  this  figure- 
of-8  tui"n  until  the  entii'e  foot  is  thor- 
oughly concealed.  It  is  best  to  cut  with 
the  scissors  each  turn  of  the  roller  about 
half  thi'ough  just  v,hen  it  crosses  the 
front  of  the  ankle,  so  that  the  accumu- 
lation of  the  bandage  at  this  point  may 
not  interfere  with  the  movements  of  the 
ankle-joint. 

The  crossings  of  the  figureof-8  band- 
age on  the  dorsum  of  the  foot  should  be 
kept  a  little  to  the  fibular  side  of  the 
median  line. 

When  the  ankle  is  reached,  the  band- 
age should  be  carried  up  the  leg  by  the 
spiral  reverse  until  the  sudden  promi- 
nence of  the  muscles  of  the  calf  is 
reached,  when,  if  necessary,  the  figure- 
of-8 reverse  should  be  practiced  to  just 
below  the  knee.  From  this  i)oint  up  to 
the  trochanter  the  simple  figure-of-8,  spi- 
ral, or  spiral  reverse,  may  be  employed, 
according  to  the  shape  of  the  limb. 
When  tlie  level  of  the  gluteal  fold  is  reached,  can-y  the  roller  obliquely 
upward  and  outward  about  half-way  between  the  trochanter  major  and 
anterior  iliac  spine,  on  across  the  sacro-lumbar  region  to  just  above  the 
upper  margin  of  the  iliac  crest  of  the  side  opposite  the  limb  being  band- 
aged, thence  downward  across  the  abdomen  and  the  groin  to  the  front 
and  outer  side  of  the  thigh,  and  back  behind  to  the  inner  side  at  the 
point  of  starting.  This  mananivre  is  repeated  until  the  entire  hip  and 
groin  are  covered,  when  the  roller  is  carried  spirally  around  the  pelvis 


Fig.  19. 


16 


A  TEXT-BOOK   ON  SURGERY. 


and  abdomen  as  high  as  the  umbilicus.  The  completed  bandage  is  shown 
in  Fig.  19.  The  j>ortion  of  this  bandage  which  goes  around  the  thigh, 
groin,  and  pelvis  is  called  the  sinr/le  spica  for  the  groin,  and  is  admira- 
bly adajited  to  the  retention  of  a  dressing  upon  a  bubo  or  wound  of 
this  region,  and  also  makes  an  efficient  temporary  compress  for  the  sup- 
]iort  of  an  inguinal  hernia.  A  double  spica  with  a  single  roller  may  be 
made  by  carrying  the  roller,  which  has  already  partially  covei'ed  in  the 
groin  and  hip  of  one  side,  directly  across  the  back  to  a  point  half-way 
between  the  trochanter  and  anterior  iliac  spine  of  the  opposite  side,  over 
the  front  of  the  thigh  to  the  inner  side,  and  thence  behind  and  outward, 
describing  a  ligure-of-8  around  the  thigh  and  pelvis  in  a  direction  the 
reverse  of  the  preceding  (Fig.  20). 

The  abdomen  and  thorax  should  be  bandaged  hw  the  simple  or  re- 
verse spiral  until  the  axilla  is  reached  in  the  male,  and  the  mammary 
gland  in  the  female. 


Fig.  20.— (After  Fischer.) 


Fig.  21.— (After  FUcher.) 


To  bandage  the  mammary  gland  it  is  best  to  place  a  thin  layer  of 
absorbent  cotton  over  this  organ,  and  under  the  axilla  as  well.  The 
roller,  about  three  inches  wide,  should  be  carried  two  or  three  times 
around  the  thorax  just  below  the  breast,  which,  if  pendulous,  should  be 
lifted  well  up  toward  the  clavicle.  If  the  right  breast  is  to  be  bandaged, 
the  operator,  standing  in  front,  should  carry  the  roller  from  the  patient's 
right  to  the  left  side,  around  the  body,  and  then  obliquely  upward  across 
the  front  of  the  chest,  catching  the  under  stirface  of  the  gland,  passing  over 
the  left  clavicle,  making  a  figure-of-8  around  the  .shoulder  and  axilla,  and 
then  across  the  back  to  the  starting-point  (see  Fig.  21).  It  is  now  carried 
directly  around  the  chest,  and,  when  the  circuit  is  completed,  again  travels 
obliquely  upward  on  a  plane  about  one  inch  higher  than  the  preceding 
turn.     This  is  repeated  until  the  organ  is  entii'ely  covered.     When  both 


BANDAGING. 


17 


(Afa-r  Fischer.) 


breasts  require  support,  the  second  may  be  bandaged  in  the  same  way  by 
an  additional  roller,  or,  as  shown  in  Fig.  22,  a  single  bandage  may  be 
thrown  around  the  thorax  and  neck  in  fig- 
ure-of-8  fashion,  so  as  to  support  both 
organs. 

Bandages  for  the  Head  and  Face. — 
For  retaining  ice-caps,  or  other  dressings 
to  the  head,  the  hood-bandage  will  be 
found  convenient,  while  its  modifications 
will  suffice  to  keep  a  dressing  upon  any 
limited  portion  of  the  scalp  (Fig.  23). 

To  apply  this,  take  a  roller  twelve  yards 
long  and  two  and  a  half  inches  in  width, 
rolled  from  both  ends  to  the  center.  Hold- 
ing one  head  of  the  roller  in  each  hand,  the 
surgeon,  standing  behind  the  patient  and 
laying  the  middle  of  the  bandage  across  I 
the  forehead  just  over  the  eyebrows,  car- 
ries one  roller  in  the  right  and  the  other 
in  the  left  hand  around  the  head,  above 

the  ears,  and  crosses  them  under  the  occiput,  so  that  the  roller  which 
went  to  the  rear  in  the  left  hand  will  travel  again  to  the  front  over  the 

same  path.  The  roller  in  the  right  hand  is  then 
carried  over  the  head,  in  the  median  line,  from  the 
occiput  to  the  nose,  and  at  this  point  it  is  caught 
and  held  down  by  the  encircling  turn  carried  in 
the  left  hand.  Then  cany  the  roller  which  came 
over  the  median  line  of  the  head  back  again  to  the 
I  /  -.f^^        rear,  so  that  its  right  edge  will  rest  on  the  middle 

((,^\  of  the  first  turn.     It  is  again  caught  under  the 

"  "  encircling  turn  at  the  occiput,  is  carried  to  the 

front  on  the  opposite  side,  and  continues  to  travel 
fi-om  before  backward  in  an  ellipse  that  is  con- 
stantly increasing,  until  it  blends  with  the  encir- 
cling turn  upon  the  sides  of  the  head,  near  the 
ears.     Each  successive  turn  of  the  elliptic  should 
leave  al)Out  one  third  of  the  turn  that  preceded  it  uncovered  in  the  cen- 
ter.    Of  course,  the  ends  will  meet  at  the  same  point,  before  and  behind, 
where  the  reverses  are  made. 

If  it  is  only  required  to  maintain  a  dressing  in  the  median  line  of  the 
scalp,  it  will  suffice  to  carry  a  circular  turn  or  two  around  the  head,  just 
above  the  eyebrows  and  ear.s,  and  below  the  occiput,  AvhUe  an  antero- 
posterior strip  is  pinned  to  this  in  front  and  behind. 

The  Head  and  Chin  Bandage  (Fig.  24)  may  be  made  to  serve  sev- 
eral purposes — namely,  to  retain  a  dressing  on  the  chin  and  lower  face, 
the  same  upon  the  scalp  at  any  portion,  and  also  for  temporary  fixa- 
tion of  the  lower  jaw  after  fracture  of  tliis  bone.  It  is  applied  as 
follows : 

2 


Fig.  23. 


18 


A   TEXT-BOOK  ON  SURGERY. 


The  end  of  a  bandage  from  one  inch  and  a  half  to  two  inches  in  width 
is  held  about  half-way  between  the  left  ear  and  the  occipital  protuber- 
ance, while  the  roller  is  carried  to  the  front  and  obliquely  across  the 
head,  just  in  front  of  the  right  ear,  uuder  the  chin,  up  in  front  of  the 
left  ear,  then  across  the  scalp,  passing  backward  between  the  right  ear 
and  occiput  to  l)eneat]i  this  protuberance,  when  it  is  cairicd  beiu'ath  the 
left  ear  straight  across  the  front  (u*  labial  aspect  of  the  chin,  and  around 
by  the  right  side  to  the  point  of  commencing.  This  manoeuvre  should 
be  repeated  several  times,  and  the  dressing  then  completed  by  carrying 
the  roller  twice  around  the  head  above  the  ears  and  eyebrows,  and  be- 
neath the  occiput,  and  pinning  a 
strip  along  the  median  line  of  the 
scalp  at  the  various  points  where 
the  turns  cross  each  other. 

Knotted  Bandaffc. — This  dress- 
ing   (Fig.    2.'))    is  sometimes   em- 


Fio.  24. 


Fio.  25.— (After  Berkeluy  Hill.) 


ployed  in  the  aiTest  of  haemorrhage  from  wounds  of  the  temporal  and 
other  vessels  of  the  scalp. 

Take  a  piece  of  cork  or  wood,  about  an  inch  in  diameter  and  one 
quarter  of  an  inch  in  thickness,  and  wrap  it  with  sublimate  gauze  or 
lint  to  make  a  compress.  Apply  this  to  the  bleeding  point,  and  lay  over 
it  the  center  of  a  double-headed  roller,  carrying  the  turns  around  the 
head,  above  the  ears.  They  are  then  crossed  over  the  comjjress,  one  end 
is  carried  under  the  chin,  the  other  over  the  top  of  the  head,  and  are 
again  crossed  on  the  opposite  temple.  Having  carried  the  rollers  again 
around  the  head,  and  crossed  them  firanly  over  the  compress,  the  ends 
are  pinned  securely  and  cut  off.  A  horizontal  slip  may  then  be  pinned 
to  the  anterior,  middle,  and  posterior  slips  of  the  knotted  bandage,  be- 
ginning in  the  median  line  on  the  forehead,  then  back  to  the  center  of 
the  middle  slip,  and  then  to  the  slip  underneath  the  occiput,  to  hold  the 
dressing  securely  in  position. 

To  band?jge  the  eye  (the  left,  for  example),  hold  the  end  of  the  strip 
half-way  lietiveen  the  right  ear  and  occiput,  and  bring  the  roller  forward 
over  the  left  eye  and  malar  eminence,  and  around  backward  beneath  the 
ear  and  occiput  to  the  i)oint  of  starting,  and  repeat  once.  When  the 
second  turn  arrives  at  the  right  ear  it  should  pass  above  this  and  com- 


BANDAGING. 


19 


pletely  around  the  skull,  just  above  the  eyebrows  and  below  the  occiput, 
in  order  to  secure  the  oblique  turn.  Complete  the  dressing  by  alternating 
between  the  horizontal  and  the  oblique  direction  of  the  roller  (Fig.  26). 

For  the  upper  lip  a  dressing  is 
readily  secured  by  a  narrow  band- 
age passing  horizontally  around 


Fig.  27. 


Fig.  '2Ij.— (After  Esniarch.) 

beneath  the  nose  and  ears,  and 
held  in  place  by  the  head-stall 
attachment,  as  in  Fig.  24. 

HandJierchief  Bandages. — In  addition  to  the  foregoing,  emergency 
dressings  for  different  parts  of  the  body  may  be  extemporized  from  pieces 
of  cloth  cut  in  vax-ious  shapes — the  so-called  TiandkercMef  bandages. 

Head  and  Face. — A  simple  hood  (Fig.  27)  may  be  made  as  follows : 
A  piece  of  soft  muslin  is  cut,  27  by  23  inches,  folded  over  for  6  or  7  inches 
along  its  greatest  measurement,  and  laid  upon  a  table,  with  the  short  piece 
underneath.  Place  the  index-finger  at  the  middle  of  the  folded  edge, 
and  turn  the  nearest  corners  toward  the  center,  forming  a  pyramid.  Now 
roll  the  remaining  straight  edge  up  until  it  is  on  a  level  with  the  edge 
which  was  turned  under,  and  place  upon  the  head,  so  that  this  edge  will 
be  put  above  the  eyebrows,  while  the  rolled  portion  comes  across  the 
occiput,  and  the  ends  are  pinned  beneath  the 
chin.  The  conical  tip  may  be  pinned  down,  if 
desired. 

The  four-tailed  cap  is  made  from  a  piece  of 
muslin,  45  inches  long  by  10  wide,  split  from 
each  end  to  mtliin  4  inches  of  the  center.  Each 
of  the  four  tails  is  5  inches  in  width.  Lay  the 
center  of  the  piece  across  the  vertex,  carry  the 
posterior  tails  forward  over  the  ears,  and  tie 
them  under  tlie  chin  and  the  anterior  backward 
beneath  the  occiput  (Fig.  28). 

The  Jiead  and  face  hood  is  made  as  follows : 
A  piece  of  soft,  light  cloth,  40  inches  square,  is  Fio.  28. 


20 


A  TEXT-BOOK   ON  SURGERY. 


folded  and  laid  across  flie  head  in  such  a  manner  that  tlie  sliortest  fold 
which  is  on  top  comes  to  the  Jevel  of  the  eyebrows,  while  the  longer 
reaches  to  the  tip  of  the  nose  (Fig.  29).     The  corners  belonging  to  the 


< 


Fio.  'J!!.— (After  Esmaroh.) 


Fic.  30.— (After  Esmaroh.) 


fold  which  is  parallel  -with  the  line  of  the  eyebrows  are  tied  snugly  be- 
neath the  chin.  The  longer  fold  is  now  turned  up  to  the  level  of  the 
eyebrows,  while  the  corners  belonging  to  it  are  drawn  forward  until 
freed,  and  are  then  carried  back  and  tied  beneath  the  occiput  (Fig.  30). 
For  holding  an  ice-bag  or  dressijig  upon  the  head,  the  sJcuU-net 
(Fig.  31)  will  be  found  of 
use.  It  is  made  of  cot- 
ton threads,  is  tightened 
around  the  head  by  a 
tape,  which  di'aws  it  to- 
gether like  the  strings  of 
a  reticule,  and  is  further 
secured  by  a  strap  tied 
under  the  chin. 

The  four-tailed  dress- 
ing for  the  eliiii  and  low- 
er jaw  is  made  by  split- 
ting a  strip  of  muslin,  6 
inches  wdde  and  45  inches 
long,  from  each  end  to 
within  H  inpb  of  the  cen- 
ter, placing  its  middle  over  the  chin,  and  turning  the  posterior  tails  up- 
ward in  front  of  the  ears  to  be  tied  over  the  vertex.  The  anterior  tails 
are  now  carried  back  below  the  ears,  crossed  once,  and  pinned  beneath 
the  occiput,  while  the  ends  are  carried  upward  and  forward  and  tied 
upon  the  forehead  (Fig.  32). 

Other  special  dressings  will  be  described  in  the  chaiJters  on  Regiona 
Surgery. 


Fio.  31.— (After  Esmarch.) 


Fig.  32. 


CHAPTER  HI. 


ANAESTHESIA. 


AncEsthesia. — Anfestliesia  means  loss  of  sensibility.  It  may  be  local 
or  general.  In  the  former,  the  sensibility  of  a  limited  portion  of  the  body 
is  more  or  less  completely  lost,  while  the  patient  remains  conscious  ;  in 
the  latter,  both  consciousness  and  sensibility  are  lost. 

Local  anaesthesia  may  be  obtained  in  a  remarkable  degree  by  the  Ju- 
dicious employment  of  the  hydrochlorate  of  cocaine,  for  the  application 
of  which  agent  to  surgical  use  the  world  will  ever  be  indebted  to  the 
Austrian,  Roller. 

The  1-,  2-,  and  4-per-cent  solutions  are  chiefly  used.  Applied  to  the 
cornea,  conjunctiva,  or  any  mucous  surface,  cocaine  is  rapidly  absorbed, 
the  capillaries  are  contracted,  and  the  end  organs  of  the  sensory  nerves 
paralyzed.  Upon  the  unbroken  integument  it  px-oduces  no  effect  what- 
ever. Injected  into  the  tissues,  it  produces  anaesthesia  wherever  it  reaches 
— in  bone,  muscle,  or  the  subcutaneous  structures.  Thrown  into  the  sub- 
stance of  a  nerve,  or  immediately  around  it,  it  is  readily  absorbed,  and 
produces  anaesthesia  in  all  parts  in  the  range  of  distribution  of  the  nerve- 
trunk  beyond  the  point  of  injection.  The  quantity  which  can  be  safely 
used  has  not  yet  been  determined.  Applied  to  the  eye,  there  is  no  dan- 
ger of  absorption  of  a  quantity  capable  of  doing  hami.  Upon  the  mucous 
surfaces  of  the  buccal  cavity  and  pharynx  several  drachms  of  a  4-per-cent 
solution  may  be  l)riished  with  acamers-hair  pencil  in  the  course  of  an 
operation  lasting  an  houi-,  for  here  the  excess  is  washed  off  and  diluted 
with  the  saliva,  which,  of  course,  should  not  be  swallowed.  Injected 
into  the  deeper  tissues,  below  the  face  and  neck,  from  twenty  to  thirty 
minims  of  a  4-per-cent  solution  should  be  the  limit  within  at  least  one 
hour  before  the  dose  is  repeated.  The  larger  quantity  should  be  used 
with  great  care  in  the  selection  of  cases.  Partial  respiratory  paralysis 
has  occurred  in  several  instances  after  the  injection  of  fifteen  minims  of 
■a  4-per-cent  solution  in  the  supra-orbital  region,  and  in  other  portions  of 
the  face.  Artificial  respiration  was  necessary  for  about  fifteen  minutes. 
Within  the  distribution  of  the  fifth  nerve  its  administration  should  be 
especially  cautious.  Chlorofdi-m  or  ether  narcosis  should  never  be  per- 
mitted while  a  patient  is  under  the  influence  of  cocaine. 

For  the  eye,  drop  two  or  three  minims  of  a  4-per-cent  solution  into 
this  organ  every  four  or  five  minutes  until  from  twenty  to  thirty  minutes 
have  elapsed.     For  light  work,  such  as  the  removal  of  a  foreign  body,  or 


22  A  TEXT-BOOK   ON   SURGERY. 

touching  tlie  lids  with  blue-stone,  the  smaller  quantity  will  suffice ;  for 
corneal  section,  iridectomy,  etc.,  the  ansesthesia  should  be  more  pro- 
found. In  the  mouth,  it  will  suffice  to  paint  the  jiart  to  be  an;esthetized 
with  the  4  per-cent  solution  by  means  of  a  camel's-hair  brush,  every  two 
or  three  minutes,  for  a  half-hour  before,  and  at  intervals  during  the  opera- 
tion. In  this  way  ulcers  may  be  cauterized,  or  limited  incisions  made  with 
perfect  insensibility,  and  by  the  employment  of  this  agent  any  irritable 
condition  of  the  mouth  and  throat  may  be  relieved.  I  have  operated 
for  cleft  of  the  soft  palate  in  an  adult  with  perfect  ansesthesia  by  this 
method. 

In  minor  surgical  operations  upon  the  extremities,  a  prolonged  and 
perfect  anaesthesia  may  be  secured  by  the  method  of  Corning,  which  con- 
sists in  injecting  the  fluid  into  the  tissues  of  the  part  to  be  anjesthetized, 
waiting  from  two  to  five  minutes  for  absorption  of  the  solution  by  the 
vessels,  and  then  keeping  the  cocaine  in  the  tissues,  by  arresting  the  cir- 
culation, with  a  rubber  tourniquet  applied  between  the  injection  and  the 
heart.  The  efficiency  of  this  method  has  been  amx)ly  demonstrated.  The 
twenty  or  thirty  minims  of  4-per-cent  solution  should  be  distributed 
equally  in  the  line  of  the  incision.  A  single  puncture  with  the  hypoder- 
mic needle  will  suffice  to  allow  the  fluid  to  be  thrown  over  an  area  an 
inch  in  length,  and  the  effect  is  so  rapid  that  the  second  puncture  can  be 
made  through  the  ansesthetized  skin.  The  needle,  after  passing  through 
the  integument,  travels  along  just  beneath  it  to  its  full  length.  One 
or  two  minims  are  then  forced  out,  the  needle  withdrawn  a  quarter 
or  half  inch,  and  a  like  quantity  discharged.  If  a  deep  incision  is  re- 
quired, the  needle  should  go  into  the  deeper  tissues.  One  advantage  of 
this  method  is  that  a  smaller  quantity  of  cocaine  will  produce  a  greater 
degree  of  anfesthesia,  and  with  less  constitutional  effect.  When  as  much 
as  thirty  minims  are  used,  the  excess  may  be  squeezed  or  pressed  out  of 
the  part,  or  washed  out  with  the  irngator.  As  to  the  length  of  time  for 
which  a  tourniquet  may  safely  remain  holding  the  part  beyond  full  of 
stagnant  blood,  I  would  say  that  a  half-hour  would  be  within  the  limit 
of  safety.  I  have  constricted  the  penis  continuously  for  an  hour  in  cir- 
cumcision, the  great  toes  on  several  occasions  for  more  than  half  an  hour 
in  removing  ingrowing  nails,  and  the  arm  for  half  an  hour  in  a  number 
of  cases.  It  is,  however,  not  always  necessary  to  entirely  arrest  the  cir- 
culation of  a  part,  for,  if  the  elastic  be  applied  close  behind  the  part  to  be 
incised,  the  superficial  compression  wiU  retard  the  flow  at  this  point, 
while  the  deeper  vessels  and  remote  capillaries  are  not  materially  inter- 
fered with. 

In  minor  operations  upon  the  trunk,  face,  head,  and  neck,  greater 
precaution  must  be  taken,  for  here  the  solution  is  carried  directly  to  the 
center.  This  is  especially  necessary  in  the  head  and  face,  for  reasons 
above  given.     A  weaker  solution  should  be  employed. 

The  deeper  injections  into  muscle  and  around  the  ends  of  broken 
bones  are  equally  efficient,  though  of  necessity  infrequent,  since  no  for- 
midable operation  should  be  undertaken  which  would  require  the  use  of 
a  large  quantity  of  cocaine.     The  details  to  be  obsei-ved  in  special  opera- 


ANiESTHESIA. 


23 


tions,  such  as  amputati(m  of  a  finger  or  toe,  cii'cumcision,  extirpation  of 
ingrowing  toe-nails,  etc.,  will  be  given  under  the  headings  to  which  these 
various  procedures  belong. 

Another  method  of  producing  local  anajsthesia  is  by  means  of  ether 
spray.  For  this  purpose  the  ordinary  Richardson's  atomizer  (Fig.  33) 
will  suffice.  In  purchasing  this  apparatus,  secure  one  with  a  silver  tube, 
not  of  glass,  for  this  is  too  fragile,  nor  of  gutta-percha,  which  is  always 
getting  stopped  up.  The  minute  atomization  of  the  ether,  and  the  con- 
sequent rapid  evaporation,  produces  an  intense  cold,  retards  or  arrests 
temporarily  the  capillary  circulation,  and  thus  paralyzes  the  end  organs 
of  the  sensory  nerves.  Everything  being  in  readiness,  an  assistant  com- 
mences the  atomization,  holding  the  end  of  the  tube  from  three  to  six 
inches  distant  from  the  skin,  so  that  the  shower  of  vapor  will  fall  upon 
the  area  to  be  incised.  The 
first  sensation  is  one  of  ex- 
treme cold,  and  is  at  times 
quite  painful,  but  this  is 
soon  followed  by  a  sense  of 
numbness,  and  later  by  a 
loss  of  all  sensation.  When 
this  is  occurring,  the  skin 
under  the  spray  changes  from 
the  normal  flush  to  a  whitish- 
purple,  which,  by  a  continu- 
ation or  sudden  increase  of 
the  force  of  the  spray,  will 

turn  white  and  become  stiff  and  frozen.  This  last  condition  is  to  be  avoid- 
ed in  general,  for  the  reaction  from  it  is  painful  and  sloughing  may  occur, 
while  a  sufficient  antesthesia  may  be  obtained  without  real  freezing.  When, 
by  pinching  with  the  forceps  or  pricking  with  the  knife,  insensibility  is 
assured,  the  oiieration  should  begin,  and  the  sjjray  be  continued.  Ether 
spray  can  not  be  employed  about  the  eye,  on  account  of  the  irritation  it 
produces,  nor  about  the  nose  and  mouth,  on  account  of  its  being  inhaled. 
It  is  in  general  inferior  to  cocaine  anjesthesia,  because  the  latter  secures 
a  more  comj)lete  insensibility,  and  the  reaction  is  far  less  painful.  Rhi- 
goline  may  be  used  instead  of  ether,  but  it  is  so  difficult  to  obtain  that  it 
has  been  superseded  by  the  ether. 

A  mixture  of  equal  parts  of  cracked  ice  or  snow,  and  salt,  applied 
directly  to  a  part  or  wrapped  in  a  thin  cloth  and  laid  upon  the  skin,  will 
produce  perfect  local  anesthesia,  and  is  a  fair  substitute  when  neither 
the  cocaine  nor  ether  can  be  secured,  and  the  emergency  demands  opera- 
tive interference.  For  fear  of  over-freezing,  the  mixture  should  be  lifted 
frequently  and  the  part  inspected. 

General  AncestJte.sia. — For  any  sini])le  oi)eration  which  must  of  neces- 
sity be  prolonged,  and  for  all  formidable  procedures  in  surgery,  complete 
and  general  narcosis  should  be  secured.  The  deliberate  conduct  of  an 
operation  which  is  scarcely  possible  when  a  i)atient  is  not  profoundly 
anesthetized,  gives  an  assurance  of  success  not  to  be  hoped  for  under 


Fig.  33.— Richardson's  atomizer,  for  the  production  of  local 
aneestliesia. 


24  A  TEXT-BOOK   OX  SURGERY. 

any  other  conditions  ;  and  when  to  this  is  added  the  ahnost  ])erfect  free- 
dom from  danger  in  properly  conducted  general  anjjesthesia,  liow  much 
more  should  the  profession  strive  to  educate  the  public  out  of  tht>  un- 
founded dread  of  taking  an  aniBsthetic.  It  is  this  fear  whicli  induces 
many  patients  to  conceal  or  silently  bear  a  malady  which,  if  operated 
upon  early,  would  prove  insignificant,  but  which,  when  left  until  pain, 
exhaustion,  or  impending  death  drives  them  to  seek  relief  at  the  hands 
of  the  surgeon,  is  too  often  formidable.  One  cause,  and  the  chief  one, 
for  this  unfortunate  condition  of  affairs,  is  the  reckless  emi)loyment  of 
these  agents,  the  lack  of  precaution  in  i)reparing  a  patient  for  narcosis, 
as  well  as  in  the  method  of  administration.  Of  the  various  ana'stlietics 
which  have  been  introduced  for  surgical  use,  only  two  deserve  to  be  con- 
sidered, and  in  order  of  preference  tliey  are  ether  and  chloroform. 

In  general,  there  is  no  comparison  between  these  agents.  Etliei-  is  so 
much  safer  than  chloroform  that  the  latter  is  fast  disappearing  in  pi-ac- 
tice.  In  the  present  rapid  progress  of  science  it  can  not  Imt  be  a  short 
while  until  chloroform  will  only  be  employed  in  a  very  limited  number 
of  cases.  The  estimated  death-rate  after  ether  is  1  in  20,000,  in  chloro- 
form 1  in  3,000.  All  of  the  ol ejections  to  ether  by  the  advocates  of 
chloroform  narcosis — namely,  its  slowness  of  action,  irritation  of  the 
respiratory  tract,  nausea  and  vomiting,  inflammability,  extra  quantity 
required,  etc. — fade  into  insignificance  when  brought  face  to  face  with 
the  fact  that  about  seven  lives  are  sacrificed  by  chloroform  to  one  by 
ether. 

In  my  opinion,  chloroform  narcosis  is  only  justified  under  the  follow- 
ing conditions : 

1.  In  children  under  six  years  of  age,  where  it  is  less  apt  to  cause  an 
accumulation  of  mucus  in  the  trachea  and  bronchi  than  ether.  Its 
more  rapid  and  less  irritating  action  renders  it  preferable  in  this  class  of 
patients. 

2.  In  women  in  childbirth  where  the  recumbent  posture  is  impera- 
tive. 

3.  In  an  emergency  where  ether  can  not  be  obtained. 

4.  In  a  patient  who  has  pi'eviously  been  in  ether  narcosis,  in  which 
dangerous  symptoms  were  caused  by  the  ether. 

.5.  In  an  emergency  where  it  becomes  necessary  to  perform  an  opera- 
tion within  two  or  three  hours  after  the  ingestion  of  a  quantity  of  solid 
food. 

6.  In  some  exceptional  cases  of  laryngeal  or  tracheal  stenosis. 

In  all  other  conditions  ether  should  be  given.  The  slowness  of  its 
action  is  an  objection  unfounded  in  fact,  for,  if  desired,  ether  narcosis 
can  be  effected  within  ten  minutes.  Irritation  of  the  respiratory  tract 
is  only  objectionable  in  younger  children,  at  which  age  the  windpipe  is 
always  narrow  and  easily  occluded,  and  the  fi"ame-work  of  the  glottis 
soft  and  readily  compressible.  IS^ausea  and  vomiting  are  objections  with- 
out value  when  the  proper  precautions  are  taken  to  prevent  the  ingestion 
of  solid  food  or  milk  for  eight  hours  before  the  administration  begins. 
The  inflammability  of  ether  requires  ordinary  precaution  in  not  allowing 


AX^STHESIA.  25 

a  light  or  cautery  point  to  be  brought  within  live  or  six  feet  of  the  ether 
cone  or  flask.  Although  I  have  used  ether  many  times  with  artificial 
light,  I  have  never  seen  an  accident,  and  do  not  hesitate  to  recommend 
its  invariable  employment  for  night-work.  The  questicm  of  bulk  or 
quantity  can  only  come  up  in  remote  military  or  frontier  practice,  where 
transportation  is  difficult. 

The  Adinhiidration  of  EtTier. — Complete  narcosis  may  be  obtained 
from  ether  administered  by  inhalation,  or  by  being  introduced  into  the 
rectum.     The  latter  method  is  rarely  practiced. 

The  following  points  are  essential  in  the  successful  administration  of 
ether:  Only  the  best  quality  of  ether  fortior  should  be  employed. 
That  manufactured  by  Dr.  Squibb  is  universally  adopted  in  America. 
It  should  have  a  .specific  gravity  not  greater  tban  0728,  should  boil 
violently  when  placed  in  a  test-tube,  subjected  to  the  heat  of  the  hand, 
and  a  bit  of  glass  is  dropped  into  it.  The  quantity  to  be  used  will 
depend  in  part  upon  the  length  of  time  required  for  the  performance  of 
the  operation,  the  construction  of  the  inhaler,  and  the  idiosyncrasy  of  the 
patient. 

As  ordinarily  given  with  the  All  is  inhaler,  which  allows  of  a  free 
admixture  of  air  and  considerable  evaporation,  to  maintain  complete 
narcosis  for  one  hoiir  will  consume  from  six  to  twelve  ounces.  The  prepa- 
ration of  the  patient  is  important.  As  just  stated,  solid  or  coagulable 
food  shoidd  be  foi'bidden  for  at  least  eight  hours  before  an  operation. 
The  bowels  should  be  moved  by  a  laxative  on  the  night  before  the  an- 
sesthetic  is  to  be  given,  and,  if  necessary,  by  enema  on  the  morning  of 
the  same  day.  Great  care  should  always  be  given  in  the  selection  of 
proper  nourishment  for  the  patient  for  several  days  at  least  prior  to  the 
operation.  Solid  food,  with  the  exception  of  the  eight-hour  limit,  is  not 
contra-indicated  unless  the  abdominal  viscera  are  involved  in  the  opera- 
tion. A  half-hour  before  the  anaesthesia  is  commenced,  about  two  table- 
spoonfuls  of  rye  whisky  or  brandy  in  a  teacupful  of  water  should  be 
taken  into  the  stomach.  If  the  patient  is  unusually  nei-vous  and  ex- 
citable, or  suffering  great  pain  or  any  marked  iiTitation  of  the  air-pas- 
sages, from  one  fourth  to  one  third  of  a  grain  of  morphia  should  be 
injected  hypodermically  about  twenty  minutes  before  the  inhalation.  It 
is  important  to  explain  to  the  j)atient  the  action  of  tlie  agent,  and,  above 
all,  to  impress  iipon  him  the  entii-e  absence  of  danger ;  that,  although  it 
will  at  first  cause  him  to  experience  a  sense  of  strangiilation  or  suffoca- 
tion, yet  this  will  last  only  for  a  minute.  Finally,  artificial  teeth  or  any 
loose  substance  should  be  removed  from  the  moiith,  and  the  clothing 
loosened  about  the  neck,  chest,  and  abdomen.  Upon  a  table,  within 
reach  of  the  etherizer  or  his  assistant,  the  follo\ving  articles  shoiild  be 
arranged  in  order : 

1.  A  wedge-  or  screw-shaped 
piece  of  wood  for  forcing  and 
holding  the  jaws  apart  (Fig.  34). 
A  Sayre's  periosteal  elevator  is  a 

good  substitute.  Fig.  S-l.— llurd-rubber  oral  scre\i~' 


26 


A  TEXT-BOOK   ON   SURGERY. 


Fio.  35. — Goodwillie's  mouth-^'a''. 


Goodwillio's  moutli-gug  iii  position. 


Mott-Heister  speculum  oris. 


2.  A  Goodwillie's  month-gag  (Figs.  35  and  36)  for  keeping  the  jaws 
permanently  separated  if  the  emergency  arises.  The  Mott-Heister  gag 
will  do  as  a  substitute  (Fig.  37). 

3.  A  strong  tenaculum,  or 
forceps,  for  drawing  out  the 
tongue. 

4.  A  large- sized  curved  nee- 
dle, armed  with  a  good  silk 
thread,  for  transfixion  of  the 
tongue  if  the  emergency  arises. 

5.  Two  or  three  curved  pro- 
bangs  with  small  sponges  tied 

on,  for  mopping  out  the  pharynx,  throat,  and  mouth  (see  Fig.  43). 

6.  Several  ounces  of  whisky  or  brandy  undiluted  ;  a  hypodermic 
syringe  filled  with  this  and  ready  for  use  ;  an  ordinary  syringe  for  a 
whisky  or  warm-water  enema. 

7.  An  extra  can  of  ether. 

8.  A  silver  trachea-tube. 

9.  A  pus-basin  or  pan,  in  case  of  vomiting. 

10.  When  an  ojieration  which  may  involve  great  lo.ss  of  blood  is  un- 

dei'taken,  a  ten-ounce  saline  solution 
for  transfusion.  The  formula  is : 
Common  salt,  gr.  xxx  ;  carbonate  of 
soda,  gr.  v ;  water,  3  x. 

If  necessary,  the  ether  may  be 
poured  directly  from  the  can  into  the 
inhaler,  but  the  bottle  shown  in  Fig. 
38  will  be  found  very  convenient, 
and,  as  it  is  graduated,  the  quantity 
used  can  be  readily  estimated. 

As  to  the  form  of  inhaler,  I  pre- 
fer that  of  AUis  (Fig.  39) : 

''The  apparatus  consists  of  a  wire 
frame- w^ork  sufficiently  large  to  cover 
the  lower  part  of  the  face.    The  wires 
are  parallel,  and  about  an  eighth  of  an  inch  apart.     Between  the  wires, 
from  side  to  side,  a  stiip  of  bandage  two  and  one  half  inches  wide  is 


J 

h 

Fig.  38. 


f  IG.  39.— Tlie  AUis  inhaler. 


ANESTHESIA. 


27 


passed.  The  instrnnient  is  only  about  four  inches  long  and  three  inches 
at  its  greatest  width,  and  yet  it  consumes  more  than  three  yards  of  band- 
age when  passed  between  all  the  wires.  By  further  reference  to  the  fig- 
nre  it  vnH  be  seen  that  each  section  of  the  bandage  is  separate  from  the 
adjoining  one,  thus  ijermitting  the  air  to  pass  freely  to  both  sides  of  it. 

"Its  advantages  are  these:  The  ether  being  very  thoroughly  mixed 
with  air,  the  patient  does  not  suffer  from  the  suffocation  usually  felt  at 
first  inhaling  ;  there  is  a  large  evajjorating  surface.  A  very  much  smaller 
quantity  of  ether  is  used,  and  less  escapes  into  the  room  than  with  the 
usual  mode  of  giving  this  ausesthetic ;  the  ether  can  be  dropped  from  a 
bottle  on  the  distal  end  of  the  inhaler  without  removing  it  fi'om  the  face  ; 
the  mask  is  soft  and  pliable,  fitting  accurately  to  the  nose  and  mouth  ; 
and,  lastly,  it  is  of  very  simple  construction,  and  can  not  get  out  of  order. 

"Over  this  frame  is  drawn  a  piece  of  stout  sheet 
India  rubber,  or  patent  leather,  which  has  been 
stitched  together  at  the  edges,  so  as  to  make  a  cov- 
ering for  the  frame,  projecting  over  one  end  two 
inches,  to  form  the  mask,  and  at  the  other  one 
inch.  The  ether  is  poured  on  the  bandage,  which 
fonns  a  close,  well-made  artificial  sponge." 

A  very  efficient  inhaler  is  represented  in  Fig. 
40,  consisting  of  a  rubber  flange,  or  mouth-  and 
nose-piece,  about  3  inches  in  diameter  and  2  in 
width,  slipped  over  the  larger  end  of  an  ordinary 
lamp-chimney.  A  sponge  is  placed  in  the  expan- 
sion of  the  chimney,  into  which  the  ether  is  sprin- 
kled, without  removing  the  apparatus,  and  through 
which  the  proi)er  quantity  of  air  can  pass  in  and 
out. 

In  an  emergency  an  inhaler  can  be  made  by 
cutting  a  piece  of  pasteboard,  12  inches  long  by  7 
wide,  shaping  and  pinning  it  in  into  a  cylinder, 
and  lining  it  with  a  folded  towel,  or  other  cloth. 
A  notch  should  be  cut  out  to  fit  over  the  nose,  and 
the  edges  softened  by  wetting.  Thickly  folded 
newspaper  will  serve  the  same  purpose.  A  hat- 
crown,  with  a  segment  removed  and  the  top  perforated,  will  answer. 
The  cloth  and  paper  cone  should  not  be  employed,  being  objectionable  in 
not  allowing  a  sufficient  admixture  of  air,  and  in  having  to  be  lifted 
from  the  face  when  additional  ether  is  required. 

In  commencing  the  administration,  which  should  be  done  in  a  room 
away  from  the  preparations  for  the  operation,  a  tea  spoonful  of  ether  is 
sprinkled  into  the  inhaler,  and  the  apparatus  held  about  two  inches  from 
the  lips,  the  assistant  standing  at  and  above  the  patient's  head.  After  a 
minute  or  two  a  teaspoonful  more  is  added,  and  the  rim  is  now  allowed 
to  rest  on  the  face.  The  i)atient  is  directed  to  breathe  freely  and  to  force 
all  the  air  out  of  the  lungs,  to  blow  through  the  inhaler,  and  to  inspire 
deeply.     No  talking  should  be  permitted  within  hearing,  except  the 


Fir..  4n.— H.  >r.  Sims's 
etber-inlialer. 


28  A  TEXT-BOOK  ON   SURGERY. 

words  of  direction  and  encouragement  fi'Dm  tlie  one  in  authority.  If  at 
the  start  an  inhaler  is  surcharged  with  ether,  and  placed  closely  over  the 
mouth  and  nose,  the  irritation  is  so  great  that  s]iasni  of  the  glottis,  with 
violent  coughing,  occurs,  and  a  sense  of  strangulation,  whicli  friglitcns  tlie 
patient,  and  causes  an  unnecessary  struggle  and  commotion.  Indiscrimi- 
nate conversation  in  the  presence  of  a  patient  who  is  being  anaistiietized 
should  be  forbidden,  since  it  often  induces  boisterous  conduct  or  un- 
guarded expressions  from  the  half-intoxicated  subject.  In  the  course  of 
five  or  six  minutes  the  degree  of  tolerance  estal)lislied  will  allow  the  ad- 
dition of  3  j  to  3  ij  of  the  anjesthetic,  and  this  may  be  repeated  in  three 
or  four  minutes.  At  this  X)eriod,  about  ten  or  fifteen  minutes  after  com- 
mencing the  inhalation,  the  face  becomes  flushed  from  capillary  disten- 
tion, the  pulse  is  considerably  increased  in  power  and  frequency,  accom- 
panied by  delirium  varying  in  character  and  degree.  If  the  patient 
should  now  begin  to  struggle  and  resist  the  inhalation,  the  assistants 
should  hold  the  arms  and  legs  firmly  against  the  bed  or  table.  When 
help  is  scarce,  this  feature  should  be  anticipated,  and  a  leather  strap  or 
rope  passed  around  the  table  or  bed  and  over  the  legs,  just  above  and 
below  the  knees,  which  should  be  tightened  at  the  proi)er  time.  The 
ai-ms  should  be  held  against  the  bed  close  to  the  sides  in  full  extension 
and  supination.  Every  few  minutes  from  twenty  to  thirty  drops  of  the 
anjcsthetic  should  be  sprinkled  into  the  inhaler.  In  from  fifteen  to 
twenty  minutes  all  movements  of  volition  cease,  the  respirations  are 
regular  and  soft,  the  pulse  is  slightly  full  and  accelerated ;  the  pupil, 
which  at  first  contracted,  is  now  dilated,  and  the  finger,  rubbed  along  the 
eyelashes  or  over  the  cornea  and  conjunctiva,  produces  no  sjiasm  of  the 
orbicular  muscle  of  the  eye  ;  the  arms  fall  limp  and  hel])less,  and  I'emain 
in  any  position  in  which  they  may  be  placed.  The  patient  is  now  in  the 
second  stage,  and  it  should  be  the  aim  of  the  etherizer  to  keep  the  nar- 
cosis just  a  little  beyond  consciousness.  If  he  is  thoroughly  trained,  this 
can  almost  always  be  done  ;  and  to  the  operator  the  sense  of  security 
from  the  danger  of  asjihyxia,  on  the  one  hand,  and  the  annoyance  of  the 
patient's  becoming  conscious,  on  the  other,  is  invaluable.  In  operating 
without  a  tourniquet,  the  color  of  the  blood  which  escapes  should  be 
noticed,  for  black  blood  indicates  asphyxia,  its  sudden  cessation  heart- 
failure. 

When  in  the  course  of  narcosis  the  respiration  becomes  markedly  ir- 
regular and  infrequent,  and  the  breathing  stertorous  in  character,  the 
indications  are  those  of  too  jiro found  paralysis,  and  the  ether  sliould  be 
temporarily  discontinued.  Lividity  of  the  face  indicates  asphyxia,  and 
demands  immediate  attention.  Asphyxia  may  occur  from  several  causes, 
and  in  any  stage  of  etherization.  In  the  first  stage,  or  stage  of  excite- 
ment, from  muscular  fixation,  the  respiratory  muscles  may  be  seized 
with  tonic  spasm,  the  chest  and  abdominal  walls  remain  immovable,  and 
the  teeth  clenched  by  the  contraction  of  the  muscles  of  mastication.  The 
veins  of  the  forehead,  face,  and  neck  become  enormously  distended,  and 
the  skin  blue.  Tliis  condition  is  not  infrequent  in  subjects  addicted  to 
chronic  alcoholism.    It  is  rare  in  other  patients  when  the  narcosis  is  gradu- 


ANESTHESIA. 


29 


ally  and  carefully  accomplished.  It  should  be  relieved  by  temporary  dis- 
continuance of  the  ether,  forcible  separation  of  the  jaws  by  means  of  the 
screw-gag,  or  other  instrument,  pulling  the  tongue  out  of  the  mouth  with 


Fio.  41. — I  Modififd  from  Esmarch.; 

a  forceps  or  tenaculum  (Fig.  41),  and  compression  of  the  thorax  by  lay- 
ing the  hands  spread  out  upon  the  lower  antero-lateral  surface  of  the 
ribs  and  pushing  inward  until  the  lungs  are  emptied,  then  allowing  the 
ribs  to  expand.  A  few  repetitions  of  this  mancenvre  will  suffice,  and  the 
administration  of  the  ansesthesia  should  be  resumed. 

In  the  second  stage^ 
or  that  of  complete  nar- 
cosis, respiration  is  fre- 
quently interfered  with 
by  the  tongue  gravitat- 
ing backward  upon  the 
larynx.  This  can  usual- 
ly be  corrected  by  plac- 
ing the  index-finger  be- 
hind the  angle  of  the 
Jaw,  and  pressing  this 
bone  directly  forward 
(Fig.  42).  The  hyoid 
bone,  fastened  to  the 
chin  by  the  genio-hyoid 
muscles,  is  thus  pulled  forward,  and  the  tongue  is  lifted  from  the  larynx. 
If  this  does  not  succeed,  the  gag  should  be  inserted,  and  the  tongiie  held 

out  by  the  tenacu- 


y 


Fig.  42. — (Esmnrch.) 


lum,  forceps,  or  silk 
thread.    AVhenever 
mucus  accumulates 
in  the  pharynx  and 
mouth,    it    should 
be  mopped  out  by 
the  sponges  tied  to 
curved  holders  (Fig.  43).     These  should  be  carried  well  back  to  the 
larynx,  and  along  the  sides  of  the  tongue  and  buccal  walls.     In  opera- 
tions about  the  mouth,  or  when  in  the  stage  of  muscular  spasm  the 


Fig.  43. 


30 


A  TEXT-BOOK   ON  SURGERY. 


tongue  has  been  woimclecl  by  the  teeth,  coagulated  blood  may  get  into 
the  larynx,  and  require  removal  by  the  sponges. 

AVheu  vomiting  occurs  in  ether  aufcsthesia,  it  is  preceded  by  a  number 
of  sijasmodic  movements  of  the  muscles  of  deglutition  and  of  the  abdomi- 
nal walls.  Ujjon  the  supervention  of  these  symptoms  thejiatient  should 
be  turned  well  over  to  one  side,  and  the  head  further  rotated  and  de- 
pressed, so  that  any  ejected  matter  will  gravitate  readily  out  of  the 
mouth  and  into  a  basin  held  in  readiness  for  this  emergency.  Not  infre- 
quently food  ingested  against  the  advice  of  the  surgeon,  or  more  than 
eight  hours  before  an  operatiim,  remains  in  the  stomach  undigested,  and 
is  vomited  during  the  ansesthesia.  This  accident  occurs  usually  late  in 
the  narcosis,  and  is  often  caused  either  by  elevating  the  patient's  head 
too  much,  or  by  allowing  him  to  come  partially  out  of  the  narcosis.  If  a 
clot  of  blood,  or  any  occluding  substance,  be  caiTied  into  the  larynx  or 
ti-achea,  and  fatal  asphyxia  becomes  imminent,  proceed  rapidly  as  fol- 
lows:  Direct  the  windows  to  be  opened,  so  that  all  the  oxygen  i)ossible 
may  be  admitted ;  slide  the  patient  over  the  end  of  the  table  until  the 
head  hangs  down,  and  tilt  the  foot  of  the  table  up  by  placing  the  lower 
legs  upon  a  stool  or  chair.  Direct  an  assistant  to  stimulate  the  respira- 
tory movements  by  bi-manual  compression  of  the  thorax  at  intervals  of 
from  five  to  ten  seconds,  while  the  operator  does  a  rapid  tracheotomy  and 
inserts  the  tube,  grasping  the  edges  of  the  wound  with  fc^rceps  to  arrest 
bleeding.  If  a  tube  is  not  at  hand,  the  windpipe  should  be  held  open  by 
retractors,  which  will  also  compress  the  bleeding  vessels.    The  method  of 


Fio.  44. 


Sylvester  should  now  be  carried  out :  Standing  at  the  patient's  head,  as 
he  rests  upon  the  inclined  tal)le,  the  operator  seizes  the  arms,  at  or  near 
the  elbow,  and  pres.ses  them  down  upon  the  thoracic  walls,  thus  forcibly 
emptying  the  lungs  (Fig.  44),  and  immediately  thereafter  extends  them 


ANESTHESIA. 


31 


upward  parallel  with  the  long  axi$  of  the  body,  aiding  in  the  free  expan- 
sion of  the  chest  (Fig.  45).  This  is  repeated  from  ten  to  fifteen  times  a 
minute,  and  kept  up  by  relays  of  assistants,  if  necessary,  until  voluntary 


Fio.  45. 


respiration  is  established,  or  the  heart  has  ceased  to  beat.  All  tliis  while 
the  mouth  should  be  kept  open,  and  the  tongue  pulled  foiT\ard  and  out 
of  the  mouth. 

Heart-failure  is  exceedingly  rare  in  the  early  stage  of  ether  narcosis. 
A  weak  heart,  as  a  rule,  is  stimulated  by  the  anjesthetic.  It  is  more  apt 
to  be  a  part  of  the  later  stage,  and  after  a  prolonged  administration  with 
loss  of  blood  or  the  added  shock  of  the  operation.  It  is  indicated  by  a 
gradual  weakening  in  the  force  and  an  increased  rapidity  of  the  pulse, 
or  by  the  rapid  supervention  of  pallor  from  sudden  stoppage  of  the 
heart.  When  the  first  condition  prevails,  pure  rye  whisky,  or  brandy, 
should  be  administered  hypodermically,  two  or  three  syringefuls  at  once 
(each  syringeful  =  3ss.),  and  repeated  at  intervals  of  a  few  minutes  until 
improvement  is  noticed.  A  like  result  may  be  obtained  by  injecting 
a  teacupful  of  warm  water  and  whisky  (equal  parts)  into  the  rectum. 
Elastic  bandages  should  be  thrown  around  the  extremities  in  order  to 
drive  all  the  blood  to  the  centers.  When  sudden  syncope  occurs,  place 
the  patient's  head  lower  than  the  body  by  allowing  it  to  hang  over  the 
upper  end  of  the  table,  while  the  lower  end  is  well  elevated  (Fig.  44). 
At  the  same  time  strike  sharply  upon  the  precordial  region  with  the 
palm  of  the  hand,  and  shower  the  chest  and  epigastiium  with  cold  water. 

Ether  narcosis  may  be  also  secured  and  maintained  by  administering 
this  agent  by  the  rectum.  This  method  was  introduced  by  Pirogofif 
about  the  year  1847.  It  consists  in  the  introduction  of  the  vapor  of 
ether  as  follows :  A  graduated  l)ottle  is  fitted  with  a  perforated  cork, 
through  which  passes  a  glass  tiibe.  To  this  pipe  a  rubber  tube  is  at- 
tached, and  at  the  other  end  is  a  glass  tube  for  introdiu-tion  into  the 
anus.     The  anal  tube  being  introduced  well  into  the  rectum,  the  bottle 


32 


A  TEXT-BOOK   ON   SURGERY. 


of  ether  is  placed  in  a  flat-bottoiqed  basin  containing  warm  water,  which 
causes  rapid  vaporization  of  the  anjesthetic,  tlie  vapor  passing  into  the 
rectum,  where  it  is  alisorbed  by  the  vessels.  The  quantity  can  be  regu- 
lated by  pressure  upon  the  tube  and  removal  of  the  warm  water.  An 
unpleasant  sensation  is  at  first  experienced,  and  this  is  soon  followed  by 
the  constitutional  eifects  of  the  agent.  Rectal  etherization  is  a  dangerous 
practice,  and  should  not  be  undertaken  under  ordinary  circumstances. 
Several  deaths  occurred  in  New  York  city  within  a  few  months  after 
the  method  was  put  in  practice.  In  one  case  rupture  through  a  rectal 
ulcer  occurred  fnnu  the  over-disteution  caused  by  the  gas,  and  in  others 
there  was  marked  injection  of  the  colon  and  rectum.  If  practiced  at  aU, 
it  should  be  reserved  for  those  extensive  operations  about  the  mouth  and 
pharyu.x,  in  which  the  presence  of  the  inhaler  seriously  interferes  with 
the  performance  of  the  operation.  Even  here  the  narcosis  should  be 
first  effected  by  inhalation,  and  then,  if  necessary,  maintained  by  the 
rectum. 

Cliloroforvi. — Pure  chloroform  is  a  colorless  volatile  liquid,  with  a 
specific  gravity  of  1'480,  not  highly  inflammable  ;  it  has  a  peculiar  odor, 
at  first  sweetish  to  the  taste,  and  afterward  burning  and  pungent.  Ap- 
plied to  the  skin,  and  prevented  from  rapid  evaporation,  it  i)roduces  red- 
ness and  vesication.  When  shaken  with  ]nire  sulphuric  acid  in  equal 
parts,  no  discoloration  ensues.  Impure  chloroform,  on  the  other  hand, 
colors  the  acid  brown. 

The  preparations  for  chloroform  narcosis  differ  in  no  essential  feat- 
ures from  those  just  given.  Since  this  anjesthetic  is  more  powerful,  a 
much  smaller  quantity  is  used.  A  simple  napkin  folded  into  a  square  of 
five  or  six  inches  will  suffice  as  an  inhaler.  The  apparatus  of  Esmarch 
(Fig.  46)  is,  however,  preferable.     It  is  composed  f)f  a  wire  frame  shaped 


Fio.  46.— (Esmarcli.) 


to  fit  over  the  nose  and  mouth,  the  center  wire  extending  up  an  inch  or 
more,  and  bent  into  a  hook.  Over  this  a  piece  of  canton-flannel  or  soft 
cloth  is  stretched  so  tightly  that  the  threads  are  parted  sufficiently  to 
allow  the  free  passage  of  air  through  the  covering.  To  the  upper  end  or 
hook  a  tape  is  attached,  and  tied  around  the  head  in  such  a  position  that 


ANESTHESIA.  33 

the  inhaler  falls  over  the  mouth  and  nose.  The  administration  is  begun 
by  pouring  twelve  or  fifteen  drops  of  the  anaesthetic  upon  the  inhaler  or 
napkin.  A  free  admixture  of  air  is  necessary.  The  napkin  should  not 
be  held  in  contact  with  the  lips  or  nose,  for  fear  of  shutting  off  the  proper 
quantity  of  air,  and  also  because  of  the  iiiitating  effect  of  chloroform 
upon  the  skin.  In  two  or  three  minutes  the  same  quantity  is  renewed, 
and  so  on  until  sensil)ility  and  consciousness  are  lost.  Chloroform  nar- 
cosis may  also  be  divided  into  three  stages. 

The  first  is  the  stage  of  excitation.  In  this  the  pulse  is  usually  in- 
creased in  force  and  frequency,  the  face  is  flushed,  the  pupil  normal  or 
contracted ;  delirium  is  jjresent,  and  a  condition  of  muscular  rigidity 
ensues,  varying  in  degree  in  different  subjects.  It  is  almost  always  well 
mai-ked  in  patients  of  the  alcohol  habit.  The  second  stage  is  that  in 
which  sensibility  and  consciousness  are  lost,  yet  in  which  the  functions 
of  the  heart  and  respiratory  organs  are  performed  in  an  almost  natural 
manner.  The  pupil  is  now  dilated  and  arterial  tension  diminished.  In 
the  third  stage,  that  of  profound  paralysis,  the  breathing  becomes  shallow 
and  stertorous,  the  heart-beats  rapid  and  weak,  and  the  arterial  tension 
is  markedly  diminished. 

The  second  is  the  operative  stage.  The  third  should  be  avoided. 
Death  during  the  inhalation  of  chloroform  occurs  from  both  heart  and 
respiratory  failure,  and  may  take  place  in  any  stage  of  the  narcosis. 


CHAPTER   n^ 


SURGICAL   OPERATIONS. 


Instruments. — Much  of  success  in  practice  depends  upon  the  pos- 
session of  a  variety  of  instruments  which  shouhl  be  of  the  very 
best  material,  made  after  well-approved  patterns,  and  as  simple 
in  construction  as  possible.     The  best  instruments  are  now  made 
with  good-sized  handles,  not  large  enough  to  be  cumbersome, 
but  sufficiently  large  to  be  grasped  firmly  in  the  hand.     For  all 
knives,  retractors,  gouges,  etc.,  the  handles  are  made  of  vulcan- 
ized rubber,  which  is  molten  on  to  the  steel,  and  does  not 
therefore  requu'e  to  be  riveted.     This  material  is  suscep- 
tible of  a  high  polish,  and  is  easily  kept  clean.     All  sur- 
faces should  be  perfectly  smooth  and  plain,  even  to  the 
extent  of  omitting  the  stamp  of  the  maniifacturer.     For 
amputations  and  ordinary  operations  on  the  soft  parts 
and  bones,  the  following  articles  are  required : 

For  making  flaps  by  transfixion,  two  ampuhttinf/- 
l- It  ires.  The  largest  of  these  (Fig.  47)*  measures  17  inch- 
es over  all,  or  12  inches  for  the  cutting  blade,  the  width 
of  which  is  five  eighths  of  an  inch.  The  rubber  handle 
has  a  cii'cumference  of  two  and  a  half  inches. 

Fig.  48  represents  a  smaller  knife  of  a  similar  pat- 
tern, the  blade  of  which  is  only  eight  inches  long  by  half 
an  inch  wide. 

The  scalpels  are  eight  in  number,  the  blades  ranging 
from  two  and  a  half  to  three  fourths  of  an  inch  in  length. 


t 


Fig.  49. 


Fig.  50. 


Fig.  47.       Fig.  4S. 


The  handles  are  large  enough  to  be  firmly  held,  and  the 

end  of  each  is  shaped  into  a  dry  dissector  (Figs.  49  and  50). 

A  probe-pointed  and  a  sharp,  curved  bistoury  (Figs. 


These  cuts  are  niiide  from  the  instrniiients  in  inv  general  operating-ease. 


SURGICAL   OPERATIONS. 


35 


Fig.  53. — Little's  lithotomy-knil'c. 


51  and  o2),  with  l)lades  of  tliree  and  a  half  inches  cutting  edge,  are  in- 
valuable in.struments. 

Twf)  lithotomy-Tcnlves 
(Figs.  53  and  54),  one 
probe-pointed,  the  other 
sharp,  with  blades  of  four 
inches  cutting  surface.. 
The  probe-pointed  knife 
is  for  the  lateral,  the  oth- 
er for  the  median  opera- 
tion. 

For  the  cutting 
part  of  tlie  opera- 
tion for  cleft  pal- 
ate, three  blades  are  need- 
ed.    A  donhh'-edffed  bis- 
toury for  commencing  the 
incision  in  trimming  the 

edge  of  the  soft  palate  I  Fig.  55),  the  cutting  edge  of  wliich  is  five  eighths 
of  an  incli  long ;  a  curved  prohc-pointed  hlstuury  of  one  and  a  quarter 

^ inch  blade  ( Fig.  56), 

^jiiiiiniiiiiiiiiiinimiii!iii!iiir,f:ii:i:;i::':::::"!N:!iiii'iiiiiiiiii  and  a  short  blade 

turned  at  almost  a 
right  angle  to  the 
.shaft  {'■'■  gum -lan- 
cet") for  dividing 
the  mucous  and  pe- 
riosteal tissues  on 
the  hard  palate 
(Fig.  57). 
For  the  subcutaneous  section  of  tendons  and  fascia,  a.  probe-pointed 
tenotome,  the  shaft  and  l)lade  together  measuring  two  inches,  the  cutting 


Fig.  .54. — Blizzard'^  probe-pomtt-d  lithutomy-knile. 


Fig.  5.5. 


Fig 


irajjjmjinjj^^ 


lil!:!!iiB::ii 


Fig.  o7. 


Fig.  58. 


Fig.  59. 


edge  of  the  blade  three  fourths  of  an  inch  long  (Fig.  58),  and  a  small 
fascia-knife  (Fig.  59)  for  multiple  division  of  the  palmar  or  plantar  fascia. 
Retractors,  or  instruments  for  holding  the  edges  and  walls  of  wounds 
steady  and  out  of  the  way, 
should  have  long  shafts 
and  handles,  so  that  the 
hands    of    the   assistants 
may    not    .shut    out    the 
light,  or  otlierwise  inter- 
fere  with    the    operator.  j,i^  «o. 


36 


A  TEXT-BOOK   ON  SURGERY. 


They  should  also  have  sharjj  or  hooked  claws  k>r  catchiug  lirni  hold  iu 
tissues  away  from  important  vessels,  organs,  or  nerves  (Fig.  60),  while 

others  should 
be  dull,  and 
curved,  or 
bent  on  the 
flat  (Fig.  61). 
A  tenacu- 
lum (Fig.  62) 
should  be  in 
every  case. 
The  aneurism-needle  (Fig.  63)  will  often  serve  a  useful  purpose  as  a  re- 
tractor. The  essential  features  of  this  important  instrument  are  a  capa- 
cious eye,  a  simple 
curve  in  one  direc- 
tion, and  a  dull 
point  which  can  not 
be  forced  into  the 
wall  of  a  vessel. 

The  instruments 
for  operations  upon 
the  bones  are  prob- 
ably the  most  important  in  the  surgeon's  outfit.     The  list  should  include 
saws,  chisels,  gouges,  elevators,  drills,  forceps,  an  exsector,  and  a  mallet 
and  trephine. 


f 


Fl<i.   M 


Fio.  63. 


'Itiij^ 


Fig.  64. — Bow-saw,  with  two  blades. 


Fig.  64  represents  the  most  convenient  saw  for  amputations  and  ex- 
sections  of  the  knee-  and  elbow- joints.  There  are  two  blades,  either  of 
which  may  be  adjusted  at  pleasure. 


Fig.  65. — Tliu  author's  adjustable  key-hole  saws. 


For  operations  upon  the  bones  of  the  face,  as  in  exsection  of  the 
superior  maxilla,  or  the  osteoplastic  operation  for  removal  of  the  spheno- 


SURGICAL  OPERATIONS. 


37 


palatine  ganglion,  etc.,  the  adjustable  key -hole  saws  (Fig.  65)  are  needed. 
There  are  three  blades,  which  can  be  attached  by  a  screw-catch  to  a 
single  handle. 

Chisels  are  of  two 
kinds — those  to  be 
driven  by  a  mal- 
let or  hammer,  and 


hand-chisels, 
curved.     Fig, 


Fig.  69. 


for  cutting   or  gouging.      They  are   straight-edged   and 
66  is  a  half -size  picture  of  ^lacewen's  osteotome.     Two  of 

these  will  be  required,  and 
should  measure,  respective- 
ly, onehalf  and  three  eighths 
of  an  incli  in  width  at  the 
cutting  edge.  A  conven- 
ient hammer  for  driving  the 
chisel  through  is  seen 
in  Pig.  67. 

Yolkmann's    sharp 
spoons  or  scoops  (Fig. 
Fig-  68.  68)    are  invaluable   in 

certain  operations. 
The  scalloped  gouges  (Fig.  69)  are  to  be  used  with  the  hand  without 
the  mallet. 

Sayre's  periosteal  ele- 
vator (Fig.  70)  meets  al- 
most every  requirement 
for  lifting  the  periosteum, 
and  is,  besides,  an  excel- 
lent bone-elevator.  For 
lifting  the  periosteum  from 
the  palute-bones,  the  three 
instruments  of  Good\\"il- 
lie  are  very  useful  (Fig. 
71). 

Bone-drills  are  not  as 
often  used  now  as  in  for- 
mer years,  yet  they  may 
be    needed    occasionally. 

One  or  two  are  burred  with  as  many  plain-edged  cutting  drills  (Fig.  72). 

For  purposes  of  econ- 
omy in  space,  a  single 
adjustable  handle  is 
arranged  for  all  the 
drills! 

Bone-  fo  rceps 

should  be  constructed 

for  cutting,  holding, 

i'li.  V2.  and  extracting   uses. 


Fii;.  70. 


38 


A   TEXT-HOOK   OX   SURGERY. 


Tliose  that  cut  ai'c  ui'  tlie  two  shapes  showTi  in  the  accoinpanying  illustra- 
tions (Figs.  73  and  74). 


G.TIEMflNN  &C0. 

Fig.  74. 


Flo.  73. 

Hamilton's  seqiiestriim-force2:>s,  an 
excellent  instrument,  is  shown  in  Fig. 
75. 

A  rongeur,  or  forceps-gouge,  is  es- 
pecially useful  in  operations  upon  the 

cranial  bones,  where  any  projecting  angles  may  be  gnawed  off,  the  em- 
ployment ui'  a  mallet  and  chisel  being  always  contraindicated  (Fig.  7(5). 

Fig.  77  represents  a 
strong  sequesfruvi-for- 
eeps,  and  Fig.   78  the 


TIEUIAtJN  &.  CO 

Fio.  75. — ilamilton'.s  seciuestrum-tbrcepa. 


-p>-=^      lion-jawed  /orcepfi,   a 
s:^^^    necessary  instrument  for 


lixation. 


Fig.  7ii. 


For  exsections  of  the  long  bones,  excepting  the  expansions  of  the 
femur  and  tibia,  at  the  knee-joint,  and  in  tarsotomy  and  other  radical 


Flo.  77. — Improved  sequebtrum-  uiid  treiianuiiig-lonq --. 

operations,  which  will  be  given  in  the  text,  the  exsector  (,Fig.  79)  is  one 
of  the  most  useful  instruments  known  to  this  date.     I  have  employed  it 


Fig.  78. 

now  in  about  all  the  exsections  possible,  and  it  has  always  met  every 
requirement.     Upon  the  very  hardest  bones,  such  as  the  inferior  maxilla, 


SURGICAL  OPERATIONS. 


39 


it  is  essential  to  have  the  saw  well  sharpened.  The  original  instrument 
was  modeled  by  Mr.  Gowan,  of  London,  but  it  was  so  complicated  in  its 
mechanism  that  I  have  had  it  extensively  modified  and  at  the  same  time 
simijlitied.     As  now  manufactured,  it  consists  of  a  four-jointed  forceps, 

the  jaws  of  which  are  at  a  right  angle  to  the 
!'  I  handles.    At  7^  is  seen  a  shield  which  not  only  ro- 

'{  f  tates,  but  is  reversible  and  readily  shifted  to  one 

\  i  or  the  other  side.     The  saw,  t,  is  chisel-shaped. 

\  I  The  outer  edge  of  the  last  tooth  is  dulled  to 

./  ^-,  prevent  wounding  the  soft  parts  surrounding  the 


bone.  The  handles  are  held  closed  by  a  clamp. ./".  After  the  periosteum 
has  been  lifted,  separate  the  jaws  to  the  required  extent,  and  slip  them 
on  between  the  periosteum  and  bone  until  the  latter  is  well  in  the  grasp 
of  the  instrument.  Close  the  handles  sufficiently  tight  to  hold  the  bone 
steady  without  crushing  it,  and  lock  them  in  the  required  position  with 
the  clamp.  The  saw  is  now  slid  into  the  Hanges  upon  the  shield  until  it 
rests  upon  the  bone,  when,  by  a  short  lateral  sawing  motion,  it  may  be 
made  to  travel  rapidly  through  the  bone.  A  very  little  care  will  prevent 
the  adjacent  soft  parts  from  being  injured. 

The  best  trephine  for  all  purposes  is  that  of  Gait  (Fig.  80),  the  burr  of 
which  is  conical.  A  convenient  size  is  one  which  measures  five  eighths 
of  an  inch  in  diameter  at  the  cutting  teeth,  and  gradually  enlarges  to 


7;£.'.;.^J. '.rnc 


Fig.  so. 


seven  eighths  of  an  inch  in  diameter  at  the  base  where  the  spiral  teeth 
terminate.  The  mechanism  of  this  instrument  is  such  that,  as  soon  as 
the  resistance  in  front  ceases,  the  side-teeth  take  hold  so  greedily  that 
the  further  rotation  of  the  trephine  is  difficult.  The  resistance  is,  how- 
ever, not  so  great  that  it  may  not  be  overcome,  and  the  teeth  driven  on 
into  the  dura  mater  and  brain,  yet  it  is  sufficient  to  warn  the  operator 
that  the  section  is  complete. 

For  the  prevention  or  arrest  of  haemorrhage  there  are  needed  a  foiir- 
niqurt,  elastic  ligatures,  various  forms  ot  forceps,  and  a  wii-e  ecraseur  or 
clamp. 


40 


A  TEXT-BOOK   ON  SURGERY. 


'"''^■M1M1I,I|||II|J 


Fig.  81. 


Esmarch's  elastic  bandage  (Pig.  81)  has  superseded  all  other  tourni- 
quets for  operations  upon  the  extremities.  The  rubber  damp  usually- 
sold  witli  the  bandage  is,  however,  use- 
less. Ea(!h  opei'ating-case  should  be 
provided  with  two  bandages  of  strong 
elastic  material  (T  jirefer  plain  white 
rubber,  which  can  be  kept  cleaner  than 
the  webbing)  about  two  inches  wide, 
and  each  bandage  about  four  yards 
long. 

The  elastic  ligature  is  a  cord  of  jilaiii 
rubber  about  two  feet  long,  and  of  dif- 
ferent sizes,  varying  from  one  twelfth 
to  one  fifth  of  an  inch  in  diameter. 

Ilcemosfdiic  forceps  should  be  of 
various  shapes.  The  four  varieties  which  I  employ  are  illustrated  in 
Fig.  82.  A  general  operating-case  should  contain  a  total  of  at  least  six- 
teen forcej)s,  and  in  the  proportion  of  two  fenestrated  mouse-tooth,  six 
broad,  solicl-Jaioecl,  four 
slencler-Jdwed,  and  four 
scissor  -  clamps  ;  the 
first  three  have  sliding 
catches,  while  the  clamp 
has  a  spring-catch  near 
the  end  of  the  handles. 
The  mouse-tooth  fenes- 
trated forceps  is  for  ac- 
curate adaptation  to  su- 
perficial vessels  of  small 
size,  while  the  broad- 
jawed  instrument  is  for 
grasping  either  large 
vessels  or  masses  of 
bleeding  tissue.  The 
points  should  be  club- 
shaped  and  perfectly 
smooth,  so  that  when 
the  ligature  is  tightened 
upon  the  instrument  it 
will  slide  over  its  tip 

and  on  to  the  vessel.  These  pieces  are  five  inches  long  and  three  eighths 
of  an  inch  across  the  widest  portions  of  the  jaws.  The  sharp-pointed 
forceps  are  useful  in  picking  up  a  vessel  which  has  retracted  or  is  deeply 
situated  in  a  wound.  The  scissor- clamps  may  be  used  for  applying  the 
double  ligatures  in  a  dry  dissection,  or  for  temjiorary  hfemostasis  of 
smaller  bleeding  points  which  need  to  be  compressed  for  a  few  minutes, 
and  then  remain  permanently  occluded. 

In  operations  in  the  various  cavities,  and  in  deep  external  wounds,  as 


FiH.  82. 


SURGICAL   OPERATIONS. 


41 


well  as  for  various  jjurposes,  to  be  given  in  detail  hereafter,  sponge- 
holders,  similar  to  those  represented  in  Fig.  83,  can  not  be  dispensed 


CTVtMKHH  8itQ 


Fig.  83. 


with.    They  should  be  solid  in  oon.struction,  10  inches  long,  some  straight 
and  others  curved. 

Every  opera  ting- ease  should  also  contain  the  following  instruments  : 
At  least  four  pairs  of  scissors — one  pair  8  inches  long,  curved  on  the 
flat,  Avith  both  points 

o 


dull  (Fig.  84) ;  another 
6  inches  long,  curved 
on  the  flat,  with  both 
points  shai'p,  for  re- 
moving sutures,  etc. 
(Fig.  85) ;  one  straight 
sharp-pointed  Sinis's 
scissors,  8  inches  long 
(Fig.  86) ;  and  a  blunt- 
pointed,  plain  dress- 
ing-scissors, 6  inches 
long  (Fig.  87).     These 

should  all  be  strong,  with  the  exception  of  the  small  sharp-pointed  pair, 
with  the  curve  on  the  flat. 


Fig.  85. — Curved  iris- scissors  ;  iilso  used  for 
removing  fine  sutures. 


Fig.  86. — Sims's  straight  scissors. 


Fig.  87. — Dressing-scissors. 


One  sliding-catch  needle-holder,  the  shape  and  mechanism  of  which  are 
fully  explained  in  Fig.  88.  The  point  should  have  a  plain  and  carved 
surface,  for  straight  and  curved  needles  (Figs.  80  to  93). 

Two  paiis  of  plain  anatomical  forceps  (Fig.  94),  fully  7  inches  long,  so 


42 


A  TEXT-BOOK   ON   SURGERY. 


Fio.  88. — Wvuth's  nuudlu-holJur. 


J)"io.  89.— Assorted  curved  and  half-curved 

tine  needles. 


G.  TIEMANN  &  CO 
Fii;.  112. — Wire  suture-needles. 


Fig.  'Jl. — Straight  and  curved  needles. 


Fig.  93. — Full-eurved  suture-needles. 


that  the  haud  may  be  kept  at  a  sufficient  distance  away  from  the  wound ; 

and  one  mouse-tooth,  8  inches  long,  with  a  sliding  catch. 

One  Nela  ton's 
porcelain-t  Ijjp  e  d 
htdlet  -  probe  ( Fig. 
9o),  one  lonf/  silver 
jjrobe,  with  an  ej^e 
at  one  end  (Fig.  96), 
and  one  or  two  gal- 
vanized  copper 
jjrohes,  from  10  to 
12  inches  long  and 
from  yV  to  \  inch  in 
diameter  (Fig.  97). 


o- 


riEWA'.N-CO. 


Jrio.  yo. — iSelaton's  bullet-probe,  with  porcelain  head. 


SURGICAL   OPERATIONS. 


43 


Two  good-sized  silver  fjrooved  directors,  0  to  7  inches  long  and  from 
\  to  -^^  of  an  inch  in  width  (Fig.  98). 


g 
P. 


I 


i£; 


Fig.  98.— Grooved  director. 

Other  instruments  will  be  given  in  the  text,  with  the  fl 

operations  for  which  they  are  especially  designed. 

Plane  of  Operation. — In  the  performance  of  a  surgical 
operation,  light  and  a  free  supply  of  fresh  air  are  of  first  im- 
portance. The  supply  of  light,  in  order  to  be  most  effective, 
shonld  fall  npon  the  operating-table  from  jooints  above  the 
level  of  the  patient.  In  the  open  air  and  in  daylight,  when 
protected  from  the  direct  rays  of  the  sun,  the  best  conditions 
for  light  and  air  prevail.  Under  shelter,  a  sky-light,  or  a 
tall,  wide  window,  are  preferable.  At  night,  gas,  lamj)s, 
candles,  or  torches,  must  often  do  the  best  service  possible 
in  an  emergency.  The  Edison  electric  light,  in  which  the 
incandescent  carbon  is  held  within  an  air-tight  globe,  fur- 
nishes the  safest  and  most  eflfective  artificial  light. 

It  is  always  desirable  to  control  the  temperature  of  an 
operating-room,  and  to  keep  it  at  a  figure  above  that  neces- 
sary, or  even  comfortable,  to  the  operator  and  attendants. 
The  patient's  body  is  almost  always  in  part  exposed,  and,  in 
addition,  is  apt  to  be  deprived  of  the  normal  body-heat  by 
haemorrhage  and  shock.  Moreover,  in  the  event  of  as- 
phyxia, the  rapid  introduction  of  fresh  air  from  the  open 
windows  may  be  imperative,  and  the  temperature  lowered 
to  a  dangerous  degree,  if  the  room  is  not  provided  with  the 
proper  means  of  heating. 

The  room  in  which  an  operation  is  to  be  performed  should 
be  large  enough  to   hold  all   the   necessary  apparatus   and 

furniture,  and  to  allow  the  free  and 
rapnd  movements  of  the  attendants  in 
the  execution  of  orders.      The  tloor 
should  be  of  wood,  tiles,  asphalt,  or 
marl)le,  uncarpeted  and   clean  ;   the 
walls  and  ceilings  equally  clean,  and  free  fi"om 
unnecessary  drapery.     In  a  dusty  country  the 
steam-spray  (1  to  20  carbolic  acid)  should  be  iised 
before  and  during  an  oi)eration  (see  Fig.  4),  and 
likewise  in  all  conditions  of  exposure  to  infec- 
tion, such  as  a  room  in  or  near  which  a  contagious 
disease  has  once  appeared,  etc. 

The  furniture  required  consists  of  an  operat- 
ing-table, at  least  two  side- tables,  or  cabinets,  for 
Adjustable  stool.        holding  trays  of  instruments,  sponges,  di-essings, 


44 


A  TEXT-BOOK   ON   SURGERY. 


solutions,  irrigators,  etc.  An  adjustable  stool  (Fig.  99)  for  the  surgeon 
should  be  among  the  accessories.  An  operating-table  should  be  made  of 
strong  material,  solidly  put  together,  6i  feet  long,  34  inches  liigh,  and  22 
in  width,  padded  with  cotton,  wool,  hair,  or  felt,  to. the  tliickness  of  about 
one  inch,  and  coA-ered  with  some  good  water-proof  material,  drawn  tiglitly 
and  tacked  to  the  edges,  so  that  no  folds  or  creases  are  left  upon  the  sur- 
face. In  modern  practice,  with  the  free  use  of  irrigating  solutions,  it  is 
necessary  to  arrange  the  operating-table  so  that  the  oil-cloth  ujjon  which 


Fin.   100. 


the  patient  is  laid  will  convey  the  fluids  in  the  required  direction  into  a 
receiving  vessel.  This  can  readily  be  effected  by  the  following  device : 
Around  two  poles  of  a  length  equal  to  that  of  the  table,  and  an  inch  or 
two  in  diameter,  roll  cotton-batting,  or  pieces  of  blanket,  until  the  Avhole 
is  about  three  inches  in  diameter.  Two  ordinary  blanlvets  rolled  tightly, 
as  shown  in  Fig.  100,  will  suffice.  At  intervals  of  a  foot  connect  these 
side-bars  by  wisps  of  bandage-cloth  long  enough  to  hold  the  bars  parallel 
with  each  other,  and  with  the  long  edges  of  the  table  on  which  thev  rest. 


SURGICAL   OPERATIONS. 


45 


This  skeleton,  or  frame,  is  lashed  securely  to  the  table,  and  an  oil-cloth  laid 
over  it  (Fig.  101).  If  the  head  of  the  table  is  raised  four  or  five  inches  on 
blocks,  the  patient  rests  in  a  kind  of  trough,  along  which  the  solutions 
are  canied  away  from  the  parts  of  the  body  not  to  be  irrigated. 

When  such  a  table  is  not  convenient,  one  may  be  extemporized  from 
an  ordinary  dining-  or  side-table,  or  two  of  these  placed  endwise.  All 
household  furniture  so  used  should  be  thoroughly  washed  and  scrubbed, 
and  then  covered  with  clean  sheets.    The  side-tables  for  dressings  should 


Fig.  101. 

be  also  cleansed  and  covered  with  sheeting.  It  is  always  important  to 
have  plenty  of  room,  so  that  the  various  articles  and  instruments  may  be 
arranged  in  the  order  in  which  they  will  be  needed.  A  hard- wood  cabinet 
(Fig.  102),  about  3  by  2  feet  (surface  measurement),  will  serve  an  excellent 
purpose  for  holding  trays  of  instruments,  ligatures,  etc.,  while  the  draw- 
ers supplied  vnth.  materials  in  reserve  may  prove  convenient  at  any  stage 
of  the  operation. 

The  trays  for  holding  instruments  submerged  in  carbolic-acid  solution 
should  be  made  of  porcelain  or  tin,  not  more  than  two  inches  deep,  and 
of  various  lengths,  to  meet  the  requirements  of  the  largest  instruments. 


46 


A  TEXT-BOOK   OX   SURGERY. 


SURGICAL   OPERATIONS. 


47 


For  ijuiposes  of  convenience,  the  tin  tray  may  be  divided  into  compart- 
ments for  the  several  outfits— one  for  the  hemostatic  apparatus,  another 
for  knives,  a  third  foi'  bone  instruments,  and  a  fourth  for  odds  and  ends. 
Every  basin  so  used, 
and  each  compart- 
ment, should  have  a 
turned  corner  like 
the  mouth  of  a  pitch- 
er for  readily  emp- 
tying the  solution 
when  necessary 
(Figs.  103,  104,  105). 

Fig.  103.— U.  M.  Sims's  instrument-trav. 


riE/.IAUiJ  S.  CO 

Fig.  100. 


Pus-basins  (Fig.  106)  are  very 
useful  for  receiving  vomited  matter 
or  for  catching  pus,  imgating  solu- 
tions, etc.  Such  vessels  should  be 
made  of  tin  or  brass,  and  not  of 
hard  rubber,  for  these  are  easily 
broken,  and  can  not  be  repaired. 

Larger  vessels,  such  as  bottles  or  pitchers,  of  glass  or  porcelain,  or 
clean  wood,  should  be  filled  with  the  various  solutions  to  be  used,  and 
kept  at  a  temperature  between  100°  and  110°  F.  As  the  operation  is  about 
to  begin,  the  irrigator  should  be  filled  with  sublimate  (1  to  3,000),  and 
the  spo7iges  placed  in  a  warm  solution  of  the  same  strength  from  which 
they  are  taken  as  required. 

The  dressings  to  be  applied  should  be  cut  and  laid  in  order,  so  that  no 
dehiy  may  be  experienced.  Ligatures  and  sutures  should  also  be  cut 
beforehand  and  placed  in  appropriate  receptacles,  the  catgut  in  oil  of 
juniper,  the  silk  or  wire  in  1  to  20  carbolic  acid. 

The  preparation  of  a  patient  has  a  moral  as  well  as  a  physical  aspect. 
The  surgeon  and  attendants  should  labor  judiciously  to  dispel  anxiety 
by  assui-ing  the  patient  of  the  safety  of  ether,  and  the  freedom  from  pain 
which  follows  even  the  most  extensive  incisions.  The  question  as  to 
whether  an  unfavorable  i^rognosis  should  be  made  known  to  the  patient 
must  be  determined  by  the  circumstances  which  prevail.  The  profes- 
sional obligation  is  discharged  when  the  nearest  relations  and  friends  are 
so  informed.  If  the  temperament  of  the  individual  is  such  that  great 
depression  would  probably  follow  the  knowledge  of  impending  disaster, 
and  thus  add  to  thn  dangers  of  the  case,  it  will  be  wise  to  advise  the 
friends  to  withhold  the  information.     The  surroundings  of  all  such  pa- 


48 


A   TEXT-BOOK    ON    SURGERY. 


tients  should  be  as  bright  and  cheerful  as  possible.  Good  light,  food, 
and  air,  and  kind  attentions  from  friendly  hands,  add  inucli  to  secure  a 
successful  issue. 

The  physical  preparation  uuiy  be  general  or  special,  and  the  time  to 
be  devoted  to  it  must  depend  in  great  measure  upon  the  nature  of  the 
disease  or  injury,  and  the  condition  of  the  individual.  If  a  condition  of 
marked  sepsis  jn'evails,  delay  is  dangerous,  for  all  efforts  at  nutrition 
will  be  more  than  offset  by  continued  absorption  of  the  poison.  The 
same  rule  will  apply  in  luemorrhage  not  conti'ollable  by  comju-ession. 
In  most  instances,  however,  much  good  can  be  achieved  by  devoting 
several  days,  or  even  weeks,  to  increasing  the  nutrition  of  the  tissues. 
Properly  selected  food  and  tonics,  the  regulation  of  the  bowels,  sound 

and  refreshing  sleeji,  and  freedom 
from  pain,  are  all  essential.  When 
the  abdominal  organs  are  to  be  ex- 
posed, esj^ecially  in  operations  upon 
the  alimentary  canal  and  the  re- 
moval of  large  tumors,  solid  food 
should  be  withheld  for  at  least  five 
days  prior  to  the  operation,  and 
concentrated  liquid  nourishment, 
such  as  beef -juice  and  nnlk,  taken 
in  its  stead.  In  addition  to  this,  a 
laxative  should  be  administered  on 
the  day  before,  and  an  enema  on 
the  morning  of,  the  operation.  Fi- 
nally, just  before  the  anaesthesia, 
the  i)arts  about  the  field  of  opera- 
tion should  be  shaved  and  cleansed, 
lirovided  that  this  is  not  painful  to 
the  patient.  The  other  features  of 
I)reparation  have  been  given  in  the 
chapter  on  Ansesthesia. 

The  preparation  of  the  surgeon 
and  attendants  is  also  of  great  im- 
portance, and  is  comprehended  in 
the  greatest  possible  personal  clean- 
liness. No  one  should  be  admit- 
ted to  the  presence  of  the  patient 
who  has  been  in  a  room  with  a  con- 
tagious disease  within  twenty-four 
houi's  thereafter,  or  who  has  not 
made  a  perfect  change  of  clothing, 
and  thoroughly  washed  all  over. 
The  nails  should  be  closely  trimmed 
and  cleansed,  the  hands  and  arms  washed  with  soap  and  water  and 
brush,  and  afterward  in  1  to  3,000  sublimate.  The  operator  should  wear 
a  water-proof  gown,  long  enough  to  reach  to  the  feet.     The  arms  should 


Fiu.  107. — Surgeon's  water-proof  operating-fiovvn. 


SURGICAL   OPERATIONS. 


49 


be  covered  with  sleeves  of  the  same  material,  pinned  at  the  shoulders  and 
extending  half-way  between  the  elbow  and  wrist  (Fig.  107).  A  linen  coat 
will  also  suffice,  but  will  not  always  protect  the  person  from  the  irrigat- 
ing solutions.     The  attendants  should  all  be  clad  in  clean  gowns. 

Everything  being  in  readiness,  and  the  patient  angesthetized,  brought 
in,  and  placed  upon  the  table,  the  following  arrangement  and  assignment 
of  duties  sliould  be  made  : 

The  table  must  be  so  turned  that  the  best  light  falls  upon  the  field  of 
operation.  All  parts  of  the  body  out  of  this  field  should  be  well  wrapped 
up  and  protected  from  getting  wet  by  blankets,  and  an  oil-cloth  over  all. 
The  parts  within  range  of  the  operation  are  now  washed  with  ether,  and 
then  with  1  to  3,000  sublimate.  If  the  tourniquet  is  to  be  applied,  say, 
to  an  extremitj",  towels  dipped  in  wiirm  sublimate,  1  to  3,000,  are  wrapped 
about  the  part,  over  this  a  sheet  of  protective,  and  the  elastic  bandage 
applied  over  these.  When  the  bandage  is  removed  up  to  the  point  where 
the  limb  is  to  remain  constricted,  this  and  all  parts  near  the  wound  should 
be  covered  over  with  warm  sublimate  towels. 

The  assistants  should  be  as  follows :  A  trained  etherizer,  and  a  first 
assistant  to  sponge  and  immediately  help  the  operator,  who  stands  usu- 
ally just  opposite  him.  A  second  assistant,  to  stand  conveniently  to  the 
instruments  and  the  operator,  whose  duty  it  is  to  hand  each  instrument 
or  article  as  called  for  with  promptness,  and  as  promptly  to  remove  those 
which  have  been  laid  aside.  A  third  assistant  attends  to  the  irrigation, 
regulating  the  supply  at  the  indication  of  the  chief.  One  supernumerary, 
for  holding  retractors,  or  perfoi'ming  any  duty  which  may  be  required. 
A  nurse  to  rinse  the  sponges  and  hand  them  to  the  first  assistant.  A 
second  nurse  to  assist  the  etherizer.  A  supernumerary  nurse  for  general 
usefulness. 

When  the  knife  (or  other 
instrument)  is  lifted  from  the 
solution,  the  assistant,  before 
handing  it  to  the  operator, 
shakes  from  it  the  few  drops 
of  fluid  which  adhere,  for  the 
acid  irritates  the  skin  and 
obscures  to  some  extent  the 
incision.  Different  methods 
of  holding  the  scalpel  in 
making  an  incision  are  rep- 
resented in  Figs.  108  and  109. 
Holding  the  handle  between 
the  thumb  and  middle  finger, 
while  the  tip  of  the  index- 
finger  rests  upon  the  back  of 

the  blade,  will  be  found  most  useful  in  cutting  through  the  skin,  and  in 
rapid  work  in  parts  of  the  body  away  from  the  more  important  vessels 
and  nerves,  such  as  the  removal  of  the  breast.     The  advantages  of  this 

position  are,  that  more  of  the  cutting-edge  is  utilized,  while  the  pressure 
4 


Fio.  108. 


50  A  TEXT-BOOK  ON  SURGERY. 

upon  the  blade  carries  it  through  the  tougher  tissues  with  less  exertion. 
^Vhen,  however,  a  careful  dissection  is  required — as  in  clenring  out  the 
axillnry  space — the  second  method,  similar  to  that  in  wliicli  a  ])('n  is  held,  is 
preferable.  It  is  always  necessary  to  stretch,  and  thus  steady,  tlic  integu- 
ment with  the  thumb  and  index  of  the  other  hand  when  an  incision  is 
made  (Fig.  110). 


Fio.  110 


Irrigation  may  be  continuous  or  interrupted,  owing  to  the  demands 
of  each  case.  Operations  in  the  joints,  or  near  an  idcer,  sinus,  abscess, 
or  any  inflamed  area,  require  exce})ti()nal  precautions.  In  clean  opera- 
tions, such  as  an  amputation  in  continuity,  where  no  inflammation  exists, 
or  the  removal  of  a  benign  tumor,  etc.,  interrupted  irrigation,  or  flushing 
the  wound  thoroughly  every  live  minutes,  will  keep  the  wound  aseptic. 

In  an  operation  which  opens  into  any  of  the  cavities  the  irrigator  can 
not  be  used  for  fear  that  the  solution  may  remain,  and  poisoning  residt 
from  absorption  of  the  corrosive  sublimate.  Asepsis  must  be  here  secured 
by  mopping  the  surfaces  of  the  wound  with  wet  sponges.  The  stronger 
sublimate  solutions  can  not  be  brought  in  contact  with  the  eye  without 
annoying  inflammation  resulting. 

The  methods  of  JicEmostasis  differ  in  different  parts  of  the  body,  and 
under  varying  conditions.  Thus,  when  amputating  an  extremity  ren- 
dered bloodless  by  Esmarch's  elastic  bandage,  or  when  the  limb  has  been 
elevated  and  an  ordinary  tourniquet  adjusted,  the  ligatiires  are  not  ap- 
plied until  the  wound  is  completed  and  the  bone  divided.  On  the  other 
hand,  when  operating  without  the  tourniquet,  it  is  essential  that  each 
bleeding  point  be  secured  as  soon  as  possible  ;  or  that  the  vessels  be  tied 
with  double  ligatures  and  afterward  divided  between  them.  This  excel- 
lent practice  not  only  serves  to  prevent  excessive  loss  of  blood,  but 
keeps  the  wound  dry  and  clear,  enabling  the  operator  to  make  a  more 
intelligent  dissection.  In  order  to  be  explicit  in  detail,  take,  for  exam- 
ple, any  major  amputation  by  the  bloodless  method.  The  flaps  having 
been  made,  the  soft  tissues  are  cut  clearly  through,  and  the  l)one  divided 
with  the  saw.  The  stump  is  now  thoroughly  cleansed  by  irrigation,  the 
cut  surfaces  dried  off  with  sponges,  and  the  ends  of  the  vessels  sought 
for  in  their  known  positions.  In  picking  up  the  end  of  an  artery  or  vein 
it  is  necessary  to  exclude  all  other  tissues,  and  especially  the  nerves, 
from  the  grasp  of  the  forceps  and  ligatures.  To  accomplish  this,  catch 
the  vessel  by  one  edge  with  a  delicate-pointed  forceps,  draw  it  out  from 
the  wall  of  the  wound,  and  from  its  sheath,  and  vaih.  a  duU  instrument, 
such  as  the  point  of  a  gi'ooved  director,  strip  the  tissues  backward  from 
the  artery  until  about  one  fourth  of  an  inch  of  the  tube  is  exposed.  A 
large,  round-pointed  forceps  (Fig.  82)  may  now  be  applied,  and  the  liga- 


SURGICAL   OPERATIONS.  51 

tiire  tied  over  this.  The  ligature  should  be  appropriate  to  the  size  of  the 
vessel  to  be  secured,  as  heretofore  given.  la  making  the  knot,  one  of 
two  methods  may  be  selected,  namely,  the  single  knot,  or  the  double  or 
friction  knot.  The  former  is  so  well  represented  in  Fig.  Ill  that  it  will 
not  require  description.  A  little  practice  will  show  the  superiority  of 
this  over  i\n^  false  knot  shown  in  Fig.  112,  which  is  more  apt  to  slip.     In 


Fig.  111.— liuet'  knot.  Flo.  U'j.— Fiilsc-  kuot.  Flo.  113.— Friction  knot. 


the  friction  or  double  knot  (Fig.  113)  the  end  of  one  side  is  passed  twice 
under  and  over  the  other  for  the  first  loop,  instead  of  once,  as  just  given. 
When  the  ends  of  the  ligature  are  drawn  upon,  and  the  vessel  con- 
stricted, the  first  knot  holds  without  danger  of  slipping  until  a  second 
single  knot  is  added  to  it.  As  to  the  application  of  one  or  the  other  of 
these  loops,  the  single  knot  will  suffice  for  all  vessels  which  are  freely 
exposed  and  superficial,  where  the  surgeon  can  be  assured  that  the  first 
turn  holds  fast  until  the  second  has  secured  it.  In  deep  wounds,  where 
the  knot  must  be  run  down  with  the  finger-tips,  as  in  the  deligation  of 
an  artery  in  its  continuity,  the  double  knot  should  be  preferred.  After 
being  tied,  the  ends  are  cut  with  the  scissors  about  one  quarter  of  an  inch 
from  the  knot.  As  to  how  much  force  it  is  necessary  or  proper  to  exert 
in  the  application  of  a  ligature  to  an  artery  it  is  impossible  to  say.  This 
point  will  be  fully  discussed  in  the  chapter  on  Surgery  of  the  Arteries. 
It  is  always  better  to  use  too  much  than  too  little  force,  for  one  of  the 
greatest  possible  annoyances  to  the  operator  is  to  be  compelled  to  open  a 
wound.  When  a  vessel  can  not  be  otherwise  foiind,  its  presence  may  be 
demonstrated  by  squeezing  the  flap  and  pressing  out  the  small  quantity 
of  blood  remaining  in  it.  In  this  way  all  vessels  of  any  size  or  conse- 
quence can  be  secured  before  the  tourniquet  is  loosened.  Before  this 
is  done  the  wound  should  be  thoroughly  irrigated,  the  flaps  opened  and 
filled  with  squeezed-out  antiseptic  sjionges,  the  whole  covered  with  warm 
sublimate  towels,  and  compression  made  with  the  hands  while  the  stump 
is  elevated  and  the  tourniquet  loosened.  After  five  or  ten  minutes  the 
wound  is  opened  and  the  sponges  removed,  one  at  a  time.  Any  bleed- 
ing points  which  may  have  been  overlooked  will  now  be  easily  seen,  and 
should  be  grasped  with  the  forceps  and  tied.  In  applying  the  forceps 
to  these  points  it  is  impossible  to  exclude  the  tissues  immediately  around 
the  vessels  from  the  grasp  of  the  instrument  and  the  ligature.  When 
using  the  broad-shouldered  forceps,  if  the  catgut-thread  is  tied  around 
the  jaws  of  the  insti'ument  and  the  loop  tightened,  the  thread  slides 
along  to  the  tip,  and,  in  slipping  off  to  constrict  the  bleeding  vessel, 
pushes  the  other  soft  tissues  to  one  side.     In  tying  such  a  ligature  care 


52  A   TEXT-BOOK  ON  SURGERY. 

must  be  taken  not  to  imU  upon  one  end  with  more  force  than  the  other, 
for  by  so  doing  the  vessel  is  torn  off  ;  and  also  to  ajjply  the  force  to  the 
thread  on  a  level  with  the  tip  of  the  forceps,  for  if  tliis  is  not  done  tlie 
vessel  is  also  pulled  out  of  the  wound  and  torn  away. 

When  all  h;eniorrhage  has  ceased,  except  the  slight  oozing  which  may 
occur  at  any  part  of  the  wound,  and  always  does  come  from  the  l^one, 
the  iri'igation  is  repeated,  and  a  diainagetube  (the  b(jue-diains  are  i)ref- 
erable)  inserted  at  each  angle  of  the  wound  at  a  point  where,  with  the 
part  in  the  position  in  which  it  must  rest  during  repair,  the  drainage  of 
serum  or  other  tluid  will  be  free  and  uninterrupted.  The  ilai)s  are 
adjusted  by  interrupted  catgut  sutures,  and  safety-pins  placed  in  the 
ends  of  the  tubes  Avhich  ])r()ject.  The  nozzle  of  the  irrigator  is  now 
placed  in  the  tube  of  one  side  and  then  the  other,  and  the  wound  dis- 
tended with  1  to  3,000  sublimate,  which  is  then  thoroughly  pressed  out 
and  the  dressing  applied  as  follows  : 

A  strip  of  sublimate  gauze  about  two  inches  \\ide  is  button-holed,  so 
as  to  fit  over  each  of  the  tubes,  and  laid  over  the  line  of  sutures,  and  on 
top  of  this  several  other  pieces  of  the  same  size.  The  stump  and  tliigli, 
up  to  the  groin,  is  now  enveloped  in  sublimate  gauze  in  layers  until  the 
whole  is  about  one  inch  thick.  Over  this  a  layer  of  absorbent  cotton  of 
the  same  thickness,  and  outside  of  this  a  sheet  of  jjrotective  which  has 
been  dipped  in  sublimate  solution.  The  whole  is  held  in  position  liy 
bandages,  which  should  be  put  on  tight  enough  to  hold  the  muscles  quiet 
and  arrest  all  oozing  from  the  wound,  and  yet  not  press  the  flaps  against 
the  end  of  the  bone,  and  thus  cause  sloughing.  Such  is  the  permanent 
antiseptic  dressing,  which  remains  unmolested  unless  pain  or  a  rise  in 
temjjerature  indicates  that,  despite  the  precautions  taken,  inflammation 
and  swelling  or  sepsis  have  occurred,  or  until  the  discharge  from  the 
wound  has  soaked  through  the  dressings  and  has  become  offensive,  hav- 
ing undergone  decomposition  beyond  the  zone  of  antisepsis. 

The  after-treatment  of  a  patient  who  has  undergone  a  major  surgical 
operation  will  depend  a  good  deal  upon  the  character  of  tlie  operation. 
The  immediate  care  should  be  to  maintain  the  vitality  of  tlie  tissues, 
wliich  has  been  endangered  by  the  shock  of  the  procedure  and  loss  of 
blood,  by  judicious  stimidation  and  relief  from  pain.  A  hypodennic 
injection  of  morphia  guarantees  relief  from  pain.  If  the  pulse  is  weak, 
and  the  temperature  low.  an  enema  of  whisky  or  the  hypodermic  admin- 
istration of  this  agent  will  stimulate  the  heart,  while  hot  applications 
will  aid  in  the  restoration  of  the  normal  temperature.  One  important 
jwint  must  not  be  lost  sight  of — namely,  that  after  a  surgical  operation 
there  is  always  a  reaction,  accompanied  by  increased  heart-action  and 
elevation  of  temperature,  and  that  while  stimulants  are  often  necessary 
in  the  stage  of  depression,  their  administration  should  be  guarded,  so 
that  they  may  not  add  to  the  fev^er  of  reaction. 

As  long  as  the  effects  of  the  ansesthe-sia  last,  a  trained  attendant 
should  remain  at  the  bedside  to  guard  against  the  danger  of  asphyxia  in 
case  of  vomiting,  to  restrain  the  pati(Mit  from  unnecessary  movements, 
or  it  may  be  to  guard  against  hajmorrhage. 


I 

CHAPTER  V. 

INFLAMMATION. 

Literally  defined,  inflammation  means  a  preternatural  heat.  In 
surgery  it  is  ajiplied  to  a  condition  of  animal  tissues  which  are  undergo- 
ing certain  disturbances  in  nutrition  which  produce  abnormal  Jiypercemia, 
heat,  redne.i.^,  swelling,  viml'pain.  Taken  singly,  none  of  these  features 
of  the  inflammatory  process  can  be  said  to  express  this  morbid  condition  ; 
they  must  all  be  present. 

It  is  well  known  that  each  of  these  conditions  may  exist  without 
inflammation,  and,  indeed,  some  of  them  are  present  in  purely  physio- 
logical processes. 

Thus,  vascular  tumors  and  the  dilated  capillary  net-works  of  certain 
forms  of  naivi,  though  characterized  by  permanent  hypersemia  and  red- 
ness, are  not  inflammatory  conditions.  Blushing,  which  is  associated  as 
part  of  the  expression  of  certain  emotions,  is  accompanied  with  no  other 
symptom  of  a  morbid  process  than  that  of  redness.  The  temj^erature  of 
the  blood  in  the  hepatic  vein  in  conditions  strictly  physiological  has 
been  registered  as  high  as  107°  F.,  and  this  extraordinary  heat  is  not 
inflammatory. 

Swelling  is  present  in  non-inflammatory  processes,  siich  as  oedema 
and  emphysema,  while  pain  is  not  infi-equent  in  certain  neuroses,  where 
all  other  symptoms  of  inflammation  are  absent.  Whether  the  cause  of 
inflammation  be  one  of  direct  injury  and  irritation  of  a  part,  or  whether 
it  be  due  to  lesions  of  the  inhibitory  nerves  or  trophic  centers  remote 
from  the  local  expression  of  the  morbid  process,  the  pathological  changes 
are  practically  the  same.  The  activity  and  violence  of  the  process  will 
depend  in  ]>art  upon  the  character  and  extent  of  the  injury,  as  well  as 
upon  the  anatomical  character  of  the  part  involved,  together  with  the 
ability  of  the  tissues  to  resist  death,  and  to  repair  the  damage  inflicted. 

The  study  of  the  phenomena  of  inflammation  may,  with  propriety,  be 
arranged  in  the  following  order:  1,  irritation;  2,  C(mtraction;  and  3, 
dilatation  of  the  vessels  ;  4,  acceleration  of  the  current  and  hypersemia  : 
5,  retardation,  partial  or  complete  ;  6,  redness  ;  7,  swelling ;  8,  heat  ;  9, 
pain;  10,  escape  of  vessel  contents;  11,  general  cell-proliferation;  12, 
formation  of  pus  ;  13,  reorganization  and  repair  ;  14,  cicatrizatit)n. 

It  is  known  that  when  a  vascular  living  animal  tissue  is  subjected  to 
irriiation,  the  vessels  in  the  zcme  of  irritation  undergo  an  instant  con- 
traction,  and   almost   instantly  thereafter   become  abnormally   dilated. 


54  A  TEXT-BOOK  ON  SURGERY. 

The  cause  of  this  contraction  is  siqiposed  to  be  due  to  stimulus  of  the 
vaso- motor  nerves,  while  the  dilatation  is  explained  as  due  to  i)a)a]ysis 
of  the  vessel-walls  from  injury  to  tlie  inhibitory  nerves,  to  chau.nes  in 
the  walls  proper,  as  the  result  of  iriltatiou,  or  to  fatigue  and  relaxation 
after  the  primaiy  contraction.  With  these  changes  in  the  vessels  which 
occur  in  such  rapid  succession,  the  blood-current  is  accelerated  ;  hyper;e- 
mia  ensues,  and  this,  in  turn,  is  followed  by  more  or  less  conii)lete  blood- 
stasis.  This  last  condition  is  most  marked  in  the  center  of  the  inflamed 
zone,  and  when  complete  arrest  occurs  it  is  first  seen  here.  At  this  stage 
leucocj-tes,  in  greatly  increased  proportion  in  the  blood,  ajipear  in  the 
venules  and  capillaries,  to  the  walls  of  which  they  adhere,  and  through 
which  they  are  seen  to  pass  by  active  amoeboid  movement,  until  they 
wander  free  in  the  intervascular  spaces  (wandering  or  emigrant  cells). 

The  bi-concave  disks  and  liquor  sanguinis  also  escape  in  the  wake 
of  the  white  corpuscles.  Conheim  has  shown  that  the  points  of  escape 
are  in  the  intervals  between  the  flat  cells  of  which  the  vessel-walls  are 
composed.     In  the  area  of  complete  stasis  emigration  does  not  occur. 

Stasis  is  very  probably  due  to  a  pathological  change  in  the  walls  of 
the  vessels,  which  in  turn  induces  in  the  blood  of  the  inflamed  area  cer- 
tain changes  whereby  the  "normal  equilibrium  existing  between  the 
blood  and  the  containing  vessels,  which  is  physiologically  essential  to 
the  integrity  of  the  circulation,  is  impaired  or  lost."  The  presence  of 
the  white  corpuscles  should  not  l)e  overlooked  in  seeking  for  an  explana- 
tion of  stasis,  for  paraglobulin,  the  coagulation  factor  of  the  blood,  is  the 
normal  property  of  the  leucocytes,  and,  as  stated,  they  are  present  in 
increased  numbers. 

Redness,  swelling,  local  increase  of  temperature  and  pain,  occur  with, 
and  as  a  result  of,  inflammatory  hyperfemia.  The  discoloration  is  due  to 
luematin  in  increased  quantity,  not  only  within  the  vessels,  but  in  the 
spaces  between  the  capillaries.  Tumefaction  is  due  to  increased  blood- 
supply,  to  extravasation,  and  cell-proliferation.  Abnormal  heat  is  caused 
by  increased  cell  activity  and  the  abnormal  conditicm  of  the  blood  with- 
in the  inflamed  area,  while  pain  is  due  to  pressure  upon  the  end  organs 
■  of  the  sensory  nerves. 

With  the  appearance  of  the  leucocytes  in  increased  numbers,  and  the 
escape  of  these  into  the  intervascular  spaces  of  the  inflamed  area,  cell- 
proliferation  occurs,  resulting  in  the  formation  of  a  common  embryonic 
tissue. 

Examined  microscopically,  this  embryonic  tissue  is  seen  to  be  com- 
posed of  protoplasmic  bodies  or  cells,  spherical  in  shape,  or  slightly 
polygonal  from  reciprocal  pressure,  varying  in  size  from  about  y^Vir  ^^^ 
j^'ttt  of  ^^  iiich,  and  often  larger  than  this.  They  may  be  nucleated, 
but  usually  appear  as  slightly  cloudy  or  granular  protoplasmic  bodies 
with  no  distinct  nucleus  or  nucleolus. 

Of  the  normal  cells,  wdiich  are  most  active  in  proliferation,  and  there- 
fore chiefly  involved  in  the  formation  of  the  new  tissue,  it  is  difficult  in 
the  present  condition  of  patholo()-ical  research  to  say.  The  followers  of 
Conheim  hold  with  him  that  the  leucocyte  is  the  chief  factor  in  this 


INFLAMMATION.  55 

process.  Others  look  to  the  connective-tissue  cells  as  of  equal  impor- 
tance with  tlie  leucocytes  ;  while  a  third  theory  is  that  all  cells  of  a 
part  responding  to  the  general  stimulus  of  the  inflammatory  process 
undergo  proliferation,  and  that  the  embryonic  tissue  is  a  common 
product. 

From  this  it  is  probably  a  safe  and  wise  deduction  to  consider  that 
the  chief  role  in  the  inflammatory  process  is  played  by  the  leucocytes ; 
that  they  not  only  proliferate,  but  by  their  presence  stimulate  active 
nutritive  changes  and  proliferation  in  the  cells  in  general,  and  that  the 
embryonic  tissue  is  in  truth  a  product  of  all  these  elements,  vai-ying  in 
degree  of  fertility.  This  conclusion  seems  to  me  rational,  inasmuch  as 
it  rests  iipon  a  physiological  foundation,  for  since  the  normal  role  of 
every  cell  element  of  the  body — whether  in  the  ^lalpighian  layer  of  the 
coverings,  or  the  endothelium,  medullo-cell,  or  connective-tissue  corpus- 
cle— is  one  of  proliferation  and  the  fonnation  of  a  new  element  to  replace 
one  which  has  flnished  its  life-history,  it  seems  reasonable  to  infer  that 
a  more  rapid  proliferation  of  the  same  cells  would  occur  under  conditions 
of  increased  hypera?mia  and  nutrition. 

The  products  of  the  inflammatory  process  may  be  organized  into  a 
permanent  tissue,  or,  failing  in  this,  may  perish.  The  peculiar  type  of 
the  new  tissue  is  probably  detennined  (1)  by  the  nature  of  the  original  cell 
from  which  it  sprung.  Thus  the  experiments  of  Goujon  showed  that  the 
medullo-cells  and  myeloplaxes  of  bones  in  young  animals,  when  injected 
into  the  muscular  tissue,  developed  into  bone  even  remote  from  the  parent 
tissue.  (2)  By  the  location  and  function  of  the  new  tissue,  as  is  shown  in 
the  development  of  exostoses  from  a  common  embryonic  tissue  near  the 
insertion  of  tendon  into  bone. 

When  the  inflammatory  process  is  rapid  and  severe,  the  new  tissue 
perishes  suddenly,  and  with  it  occurs  the  rapid  death  or  gangrene  of  the 
old  tissues  involved..  Under  milder  conditions  the  supply  of  nutrition 
may  be  more  gradually  diminished,  and  the  embryonic  cells  undergo 
fatty  degeneration  and  absorption.  It  is  then  said  to  have  undergone 
resolution.  Again,  and  not  lancommonly,  the  cells  of  the  new  tissue, 
partly  granular  and  partly  unchanged,  are  found  floating  in  a  fluid,  the 
liquor  j)ijrls. 

Sj/mptoms. — In  the  milder  forms  of  inflammation  no  symptoms  may 
be  observed  beyond  the  local  disturbance.  In  other  and  severer  types 
the  elevation  of  temperature  is  often  well  marked,  and  not  infrequently 
preceded  by  or  accompanied  with  a  series  of  rigors,  or  a  pronounced  chill. 
This  is  especially  apt  to  occur  in  erysipelas,  dermatitis,  and  any  form  of 
phlegmon.  The  pulse  is  accelerated,  the  tongue  is  dry  and  coated,  thirst, 
anorexia,  and  headache  follow  in  the  train  of  syni2)toms  which  are  com- 
mon in  septic  fever — the  fever  of  inflammation. 

Treatment. — The  measures  to  be  employed  are  local  and  general.  The 
immediate  indication  is  rest  of  the  part  inflamed.  If  one  of  the  extremi- 
ties is  involved,  an  elevated  positicm  by  means  of  a  sAvinging  cradle  (Fig. 
114),  or  upon  a  pillow,  will,  as  a  rule,  give  the  greatest  degree  of  comfort, 
especially  in  cases  where,  by  reason  of  the  swelling,  the  circulation  in  the 


56 


A  TEXT-BOOK   OX  SURGERY. 


veins  beyond,  the  infiltrated  portion  is  interfered  witli.  In  siirli  con- 
ditions;! flniini^l  iKindiiiif,  jjroperly  iipplii'd  Troin  Ihe  end  of  the  <'xtrenuty 
up  to  the  inlhimed  area,  will  he  ad\isable.  If  the  swelling  becomes  so 
intense  as  to  threaten  gangrene,  or  even,  by  excessive  tension  of  the  part, 


Flo.  114. — Fluhrur'ri  swin-jrini^  cradle  (Mt.  Sitiai  Hospital). 

to  2;iv-e  extreme  pain,  free  incisions  should  be  made  i)aiallel  with  the  axis 
of  the  limb,  extending  well  through  to  the  deep  fascia,  and  through  this 
if  necessary.  These  incisions,  made  so  as  not  to  divide  the  vessels,  should 
be  left  open  and  treated  with  strict  antisepsis. 

Blood-letting,  either  by  venesecticm  or  by  leeches,  or  scarification  and 
cu])ping,  are  to  be  employed  in  certain  selected  cases.  In  plethoric  indi- 
viduals, with  high  febrile  movement  and  bounding  pulse,  venesection 
may  be  done  with  marked  and  immediate  benetit.  The  operation  should 
be  performed  in  the  median  cephalic  vein  as  follows  (Fig.  115) :  Apply  a 
bandage  around  the  middle  of  the  u])per  arm  sufficiently  tight  to  occlude 
the  veins,  but  not  to  arrest  the  arterial  circulation.  Produce  local  anjes- 
thesia  at  the  point  of  incision  by  injecting  fi-om  5  to  10  minims  of  4-per- 
cent cocaine  beneath  the  skin  in  the  line  of  th(»  median  cephalic  vein  [not 
median  hasilir).  Ether  spray,  or  salt  and  ice,  may  be  employed  if  cocaine 
can  not  be  obtained.  Make  an  incision  from  a  half-inch  to  one  inch  long, 
varying  with  the  amount  of  sulx'utaneous  fat,  and  directly  over  the  vein 
until  it  is  well  ex[)o.sed.  With  a  curved  i)air  of  scissors  now  make  a 
valvular  slit  about  half  through  the  vein.  The  amount  of  blood  to  be 
withdrawn  will  lie  detennincd  by  the  impression  made  upon  the  radial 
pulse  of  the  opposite  arm,  and  in  part  by  the  sensation  of  the  patient. 
From  8  to  16  ounces  will  usually  suffice. 


INFLAMMATION. 


57 


When  ready  to  arrest  the  flow,  jilace  a  pellet  of  absorbent  cotton, 
moistened  in  1  to  3,000  srd^limate,  over  the  wound,  hold  it  fir-mly  here, 
and  then  remove  the  ligature.  A  jdece  of  sublimate  gauze  is  now  laid 
over  the  wound,  and  held  in  place  by  a  moderately  tight  bandage. 

If  leeches  are  to  be  employed, 
from  six  to  a  dozen  or  more 
should  be  applied  directly  to 
the  inflamed  area.  If  a  drop  of 
blood  is  drawn  ont  by  the  i>rick 
of  a  needle,  or  warm  milk 
dropped  on,  they  will  take  hold 
more  readily.  Once  attached, 
they  should  be  allowed  to  drop 
off  of  their  own  accord.  If  the 
oozing  from  the  wound  is  too 
prolonged,  it  can  be  arrested  by 
a  sublimate  compress. 


Fig.  110— Tcn-bladed  scarificator. 

Scarification  is  now  rarely 
practiced,  since  freer  incisions 
are  to  be  prefeiTed.  When  per- 
formed, it  consists  of  making 
a  series  of  small  cuts  into  or 
through  the  inflamed  integu- 
ment by  means  of  a  number  of 
lancets,  driven  by  a  spring  with 
almost  painless  rapidity  (Fig. 
116). 

Compression  applied  to  the 
main  artery,  going  to  the  part 
inflamed  at  a  point  removed  from  the  zone  of  inflammation,  is  impracti- 
cable and  of  doubtful  l)eneflt.  The  constriction  of  the  artery  without 
also  partly  occluding  the  vein  is  scarcely  possible  except  by  digital 
compression,  or  the  u.se  of  the  pole- com  press,  shown  in  the  treatment  of 
aneurism. 

The  local  application  of  cold  is  of  great  benefit,  and  usually  affords 
much  comfort  in  the  treatment  of  inflammation.  One  of  the  most  useful 
and  cleanly  methods  of  applying  it  is  to  ^ilace  crushed  ice  in  the  well- 


Fio.  115. — (Jloditied  from  Esmarch.) 


58 


A  TEXT-BOOK  ON  SURGERY. 


known  rubber  ice-bag  (Fig.  117).  AVlien 
these  ciin  not  be  obtnined,  the  blad- 
ders and  stomachs  of  animals,  properly 
cleansed,  can  be  substituted.  Ice-water 
can  be  employed  by  means  of  an  irri- 
gator, with  a  stop-cock  to  regulate  the 
flow,  or  by  placing  a  pitcher  or  basin 
containing  the  water  immediateh'  above 
the  part,  and  dipping  into  this  a  twist  of 
soft  cotton  or  linen  cloth,  allowing  one 
end  to  hang  directly  over  the  inflamed 
area  in  such  a  ]iosition  that  the  constant 
drip  will  fall  upon  it  (see  Fig.  7).     Or  a 


Fig.  117. — (From  Esmarch.) 


Fui.  118. — ,  MoJifiuJ  from  Fischer.) 


INFLAMMATION.  59 

piece  of  tubing  may  be  used  as  a  siplion  to  the  flow,  regiilated  by  a 
safety-pin  clamp. 

A  coil  of  rubber  tulnng  wound  ai'ound  or  upon  an  inflamed  surface, 
through  wliich  cold  water  i^  allowed  to  run  continuously,  is  an  efl'ective 
method  of  applying  cold  (Fig.  118).  This  apparatus  is  objectionable  in 
some  instances  on  account  of  its  weight.  Submerging  an  inflamed  ex- 
tremity in  a  vessel  of  cold  water  may  also  be  efiicacious. 

Heat  may  be  applied  by  employing  the  same  apparatus  as'for  cold.  The 
ice-bag  may  be  filled  with  hot  water,  or  hot  iiTigation  used.  Cloths  rinsed 
in  hot  water  and  laid  over  the  inflamed  surface  is  one  of  the  readiest 
and  best  methods  of  utilizing  heat  in  the  treatment  of  inflammation. 
Poultices  of  flaxseed-meal,  or  of  bread,  applied  and  kept  moist  and 
warm,  are  also  useful  local  applicatitms.  A  poultice  used  on  a  broken 
surface  should  be  made  with  1  to  10,0'00  sublimate  solution. 

In  determining  whether  heat  or  cold  will  be  used  in  any  given  case, 
the  surgeon  must  be  guided  in  part  by  the  sensibility  of  the  patient,  for 
that  which  is  most  grateful  to  the  part  inflamed  will  usually  produce  the 
most  satisfactory  results. 

Counter-irritants,  such  as  blisters,  sinapisms,  or  the  cautery,  are  use- 
ful at  times  in  the  therapy  of  inflammation,  especially  in  chronic  pro- 
cesses in  the  joints  and  deeper  tissues. 

Internal  Medication. — As  far  as  the  constitutional  treatment  of  inflam- 
mation is  concerned,  each  case  will  be  a  law  unto  itself.  In  the  stronger 
and  plethoric  patients  a  saline  or  a  calomel  purge  is  indicated  in  the 
beginning  of  the  process,  and  restricted  diet  should  be  insisted  upon. 
For  the  more  feeble  class  of  cases,  tonics,  cod-liver  oil,  good  air,  and  well- 
directed  nourishment  are  essential.  To  counteract  the  high  febrile  move- 
ment and  rapid  pulse,  antipyrine  in  doses  of  gr.  x  to  xx,  repeated  in 
two  hours,  is  an  excellent  remedy.  Aconite  tincture,  gtt.  ij,  and  one 
drop  additional  every  half  hour  until  the  pulse  falls,  is  also  to  be  recom- 
mended. Quinia  in  doses  of  gr.  x  twice  a  day,  or  even  oftener,  in  case 
of  chills  or  rigors.  Morphia,  or  one  of  the  hypnotics,  should  be  given 
when  positively  indicated  by  the  patient's  suiferings  from  pain  or  loss  of 
sleep. 

Suppuration. — In  its  recent  state,  pus  is  a  cream-like  fluid,  in  specific 
gravity  varying  from  1  "020  to  1  '040,  and  at  times  higher.  In  closed  cavi- 
ties in  the  tissues  it  is  usually  alkaline  in  reaction,  but  when  exposed  to 
the  atmosphere  (and  in  some  instances  even  within  the  tissues,  where  it  is 
protected  from  the  air)  it  becomes  acid.  Chemically  it  may  contain  para- 
globulin,  myosin,  fatty  acids,  leucin,  tyrosin,  cholesterin,  chloride  of 
sodium,  and  phosphates.  Healthy  pus  is  odorless,  but  when  decompo- 
sition has  occurred  the  odor  is  often  exceedingly  offensive. 

Examined  microscopically,  numerous  corpuscles,  varying  in  size  from 
stVtt  to  -^-^  of  an  inch,  are  seen  floating  in  a  transparent  fluid — the  liquor 
puris.  These  cells  have  no  limiting  membrane,  contain  one  or  several 
nuclei,  and  at  times  a  number  of  fine  granules,  and  can  not  be  differen- 
tiated from  the  white  l)lood-corpuscle  or  the  common  embryonic  cell. 

Another  cell-like  body  found  in  pus,  especially  in  older  abscesses,  or 


60 


A   TK  XT-BOOK   ON   SURGERY. 


where  a  chronic  inflammatory  process  has  occurred,  is  tlie  granular  eor- 
puNcIe,  or,  as  it  is  more  commonly  CiilUnl,  the  compound  <ir;inuhir  cor- 
piiscle.  The  pus-(!or])uscles  proper  are  knicocytes  anil  dead  embryonic 
tissue-cells.     The  compound  granular  corpuscles  are  made  up  of  an 

aggr(>n;ation  of  .ii-raiiules, 
the  detritus  of  leuco- 
cytes, embryonic  tissue, 
or  other  cells,  which 
liave  undergone  fatty 
or  granular  metamor- 
])hosis.  These  adhere 
together  in  spherical  or 
oval  masses  of  all  sizes, 
often  as  large  as  a  dozen 
pus -cells  together,  or 
the  granules  may  float 
I'l'ee  in  the  liquor  puris. 
The  ditt'erentiation  of 
these  elements  is  not 
difheult.  Upon  the  ad- 
dition of  acetic  acid  the 
pus -corpuscles  become 
swollen,  and  lose  their 
granular,  cloudy  ap- 
])earance,  while  their 
nuclei,  otherwise  scarce- 
ly recognizable,  stand  out  in  strong  relief.  Acetify  acid  does  not  affect 
the  granular  corpuscle,  which,  however,  is  soluble  in  ether.  Pus-cor- 
puscles proper  are  at  times  endowed  with  the  amoeboid  movement.  This 
is  only  true  of  the  white  blood-cell,  which  has  not  yet  jjerished.  The 
dead  embryonic  cells  do  not  possess  the  power  of  motion. 

These  various  elements  of  pus,  as  well  as  the  cholesterin  crystals, 
which  are  sometimes  met  with,  are  shown  in  Fig.  119. 


Fio.  119. — fllodifiefl  from  Tlionias.)  a,  Compound  granuliir  coijrns- 
cles.  b,  Crystals  of  cliolestcriii.  c,  I'us-cclls.  </,  Sumo  after 
addition  of  acetic  acid. 


Fig.  120. — Micrococci  and  bacteria,     (.\fter  Sternberg  and  Magnin.) 

Pus-corpuscles  and  the  liquor  puris  frf)m  all  acute  abscesses,  whether 
communicating  with  the  atmosphere  or  not,  contain  also  certain  micro- 
organisms known  as  micrococci  and  bacteria  (Fig.  120).     These  organisms 


INFLAMMATION. 


61 


;  ^Ofi'tif  of  Abscess. 


usually  disappear  from  abscesses  of  long  standing — the  cold  absce-tses. 
Their  chief  significance  is  that  they  give  to  pus  a  septic  power,  or  that 
pus  which  contains  them  injected  or  absorbed  into  the  blood  produces 
septic  fever — a  condition  which  does  not  follow  the  injection  of  pus  which 
does  not  contain  these  elements.  As  before  stated,  pus-corjiuscles  may 
disappear  by  granular  metamorphosis,  the  liquor  puris  is  carried  off  by 
the  tissues,  and  in  many  abscesses  of  long  standing  nothing  remains  but 
a  half-dried  mass  of  cheesy-looking  granular  matter. 

When  pus  collects  in  any  part  of  the  body  in  a  recognizable  quantity, 
such  collection  is  called  an  abscess.  If  it  is  well  defined,  held  in  a  given 
position  by  a  limiting  membrane  or  wall,  it  is  a  circumscribed  abscess, 
and  diffuse  when  it  widely  infiltrates  the  tissues.  A  rapid  and  recent 
collection  of  pus  is  called  an  acuie  abscess  ;  a  slow,  chronic,  and  ancient 
collection,  a  cold  abscess. 

The  limiting  membrane  or  wall  of  a  circum- 
scribed abscess  is  a  new  formation  of  inflammatory 
origin,  a  granulation  tissue,  studded  with  capillary 
loops,  as  in  the  embryonic  tissue  of  a  wound  under- 
going repair  (Fig.  121).  It  is  in  part  a  pyogenic 
membrane,  since  it  furnishes  the  dead  embryonic 
cells  which  float  off  into  the  abscess,  while  the  leu- 
cocytes wander  in  from  the  capillary  circulation. 

A  diffuse  abscess  results  from  the  pro]ierty  which 
pus  possesses  under  certain  conditions  of  dissolving 

all  connective  and  embryonic  tissue.  It  thus  meets  with  no  barrier  to 
its  progress,  and  general  infiltration  occurs. 

A  chronic,  subacute,  or  ^'- cold  abscess''''  differs  from  the  preceding  in 
the  slowness  of  its  development,  and  usually  in  the  absence  of  those 
synq^toms  of  local  and  constitutional  disturbance  which  characterize  the 
acute  formation  of  pus.  They  occur,  as  a  rule,  in  diseases  of  bone  and 
joints,  and  in  individuals  of  low  vitality.  Cold  abscess  is  not  infrequent 
after  caries  of  the  spine,  and  after  adenitis  of  the  axillary  region. 

Diagnosis. — The  recognition  of  an  acute  abscess  will  depend  upon 
certain  s.ymptoms  of  a  local  as  well  as  a  constitutional  character.  The 
local  signs  are  those  of  infiammation,  which  precedes  as  well  as  co-exists 
with  the  pus  formation.  Heat,  pain,  redness,  and  swelling  are  therefore 
among  the  earlier  symptoms.  Fluctuation  is  also  present  in  well  advanced 
cases.     The  integument  and  subcutaneous  tissues  about  an  abscess  are 


Fio.  121.— (Afler  A^'iiew.) 


Fig.  122. — Exploring-iieedle  and  syringe. 


often  opdematous  and  doughy,  becoming  pale,  and  pitting  under  the 
finger.  The  positive  test  as  to  the  presence  of  pus  in  quantity  is  aspira- 
tion. For  this  purpose  the  hypodermic  syringe,  with  an  extra  large  and 
long  needle  (Fig.  122),  is  invaluable.  The  following  precautions  should 
be  practiced  :    The  entire  instrument  should  be  thoroughly  cleansed  and 


62  A   TEXT-BOOK   ON   SURGERY. 

submerged  in  a  5-per-cent  carbolic-acid  solution.  Tlio  slviu  at  tlie  point 
to  be  punctured  should  be  washed  with  sublimate  solution  and  ether,  and 
the  needle  jiushed  in  so  as  not  to  wound  any  vessels  or  nerves.  If  it 
has  entered  the  cavity,  upon  withdrawing-  the  jiiston  the  pus  will  escape 
into  the  chamber.  The  fluid,  if  any  doubt  exist,  should  then  be  placed 
under  the  microscope.  As  the  needle  is  withdrawn,  the  wound  should 
be  covered  with  sublimate  gauze,  held  in  place  with  a  roller  or  adhesive 
strip. 

Ill  cold  abscess  the  inflammatory  and  sejitic  phenomena  arc  absent, 
and  Uuctuation  may  or  may  not  be  appreciable.  Aspiration  will  deter- 
mine the  character  of  the  swelling. 

Treat incnf. — "When  an  acute  abscess,  either  circumscribed  or  diffuse, 
exists,  it  should  be  freely  evacuated,  and  the  sooner  the  better.  When 
the  abscess  is  situated  in  a  portion  of  the  body  where  there  are  no  impor- 
tant vessels  or  organs  in  danger  of  being  wounded,  a  sharp-pointed, 
cui'ved  bistoury  should  be  carried  through  the  wall,  and  the  cavity 
opened  by  ciitting  outward.  These  minor  operations  may  be  done  with 
cocaine  anaesthesia.  In  the  neck  or  other  vascular  regions,  or  wli(>re  an 
abscess  complicates  a  hernia  or  other  important  viscus,  a  careful  dissec- 
tion should  be  made  from  without  inward.  The  point  of  greatest  impor- 
tance is  to  have  the  opening  or  openings  in  such  a  i^osition  that  the 
drainage  will  be  from  the  most  dependent  portion  of  the  cavity.  In 
cutting  down  upon  an  abscess  it  is  often  necessary  to  insert  a  small-sized 
aspirator-needle  and  determine  the  exact  distance  to  the  pus.  The 
needle  should  be  left  in  i^lace  as  a  guide.  In  some  of  these  cases,  in 
order  to  avoid  haemorrhage,  a  very  good  use  may  be  made  of  the  ordi- 
nary dressing-forceps,  by  closing  the  jaws  of  the  instrument  and  pushing 
it  through  the  tissues  into  the  pus,  and  then  stretching  the  puncture  thus 
made  by  forcibly  separating  the  handles. 

As  soon  as  an  abscess  is  opened  the  nozzle  of  the  irrigator  should  be 
introduced,  and  the  cavity  well  washed  out  with  sublimate  (1  to  .3,000). 
After  this  rubber  drains  should  be  inserted,  and  a  thick  dressing  of  subli- 
mate gaxize  applied. 

When  an  abscess  occurs  in  parts  of  the  body  where  it  is  desirable  to 
avoid  leaving  a  scar,  as  the  neck  or  face,  and  wliere  the  symptoms  of 
sepsis  arc  not  marked,  a  cure  may  be  effected  by  means  of  the  aspirator. 
For  this  operation  the  instrument  reitresented  in  Fig.  123  is  preferable. 

It  consists  of  a  syringe,  with  a  glass  cylinder,  armed  with  a  double 
tip,  a  stop-cock,  and  two  adjustable  rubber  tubes — to  one  of  which  the 
needle  is  tightly  screwed.  When  about  to  be  used,  the  apparatus  should 
be  thorougiily  cleansed  in  1  to  20  carbolic-acid  solution,  and,  if  the  needle 
has  been  used  in  any  suspicious  matter,  it  should  be  heated  to  a  red  heat 
over  a  spirit-lamp,  and  cooled  off  in  1  to  20  carbolic-acid  solution.  TIk^ 
method  of  hyper-distentinn  of  an  abscess  with  an  antiseptic  fluid  was  flrst 
prominently  brought  before  the  profession  by  Mr.  Callender.  The  cylinder 
should  be  filled  with  the  solution,  and  then,  while  holding  the  needle 
upward  so  that  any  air  which  may  have  entered  by  accident  will  escape 
first,  the  contents  should  be  forced  out  until  only  about  one  third  of  the 


INFLAMMATION. 


63 


cylinder  is  full.  By  this  manoeuvre  the  needle  and  tube  are  also  filled 
with  the  solution,  and  the  former  is  thrust  into  the  cavity  of  the  abscess 
and  held  steady  by  an  assistant.  The  operator  now  withdraws  the  piston 
slowly,  so  as  to  give  the  contents  sufficient  time  to  fill  the  tube,  which 


Fig.  123.— Combined  a.<pirator  and  irri^'ator. 

Otherwise  would  collapse  from  atmospheric  pressure.  As  soon  as  the 
cylinder  is  full  the  stop-cock  is  turned,  so  as  to  open  tlie  emptying  tube, 
which  motion  also  closes  the  one  communicating  with  the  abscess.  The 
contents  of  the  cylinder  should  now  be  emptied,  and  the  evacuation  con- 
tinued until  the  pus  ceases  to  flow.  The  syringe  should  now  be  filled 
with  the  1  to  20  carbolic-acid  solution,  and  the  abscess  injected  until  its 
walls  are  over-distended,  when  the  fiuid  is  withdrawn.  This  irrigation 
and  hyper-distentiou  may  be  repeated  several  times,  until  the  fluid  runs 
out  clear.  The  needle  is  then  removed,  a  i)lng  of  sublimate  gauze  x)laced 
over  the  puncture,  a  sublimate  gauze,  cotton,  and  protective  dressing 
over  this,  and  a  bandage  applied  over  all  tight  enough  to  compress  the 
opposite  walls  of  the  abscess  firmly  together. 

In  asjjiration  of  an  abscess  it  is  usually  best  to  employ  the  large-sized 


fi4  A  TEXT-BOOK  ON  SURGERY. 

needle,  for  tliick  pus  escapes  with  <iieat  difficulty  tliron<rh  the  small 
points.  It  is  not  infrequently  necessary,  even  when  a  large  needle  is 
used,  to  dilute  the  contents  of  the  sac  by  forcing  in  a  quantity  of  the 
liquid  before  it  can  be  brought  out  by  the  exhaustion.  Some  operators 
prefer  to  use  sublimate  (1  to  3,000)  rather  than  carbolic  acid.  When 
mercury  is  employed,  great  care  should  be  observed  in  thoroughly  evacu- 
ating the  sac  before  applying  the  dressing,  for  fear  of  ])oisoniug  by  ab- 
sorption. One  operation  is  often  sufficient  to  effect  a  cure  by  this  method, 
and  when  carefully  done  to  the  exclusion  of  air,  and  with  the  thorough 
cleansing  of  the  abscess,  constitutional  disturbance  is  rare.  A  second, 
and  even  a  third,  injection  and  irrigation  may  be  tried.  Should  inflam- 
mation and  sepsis  follow,  free  incision  should  be  jjracticed  and  thorough 
drainage  established. 

Cold  Abscess. — Old  abscesses  which  produce  no  deformity  or  marked 
discomfort  to  the  patient  may  be  left  alone.  If  at  any  time  symptoms  of 
inflammation  and  sepsis  supervene,  prompt  and  free  incision  and  iiriga- 
tion  should  be  done,  and  drainage  maintained.  When,  by  reason  of  its 
situation,  it  becomes  advisable  to  oj^erate  upon  a  non-inflamed  cf)ld 
abscess,  aspiration  and  irrigation  should  be  performed  in  the  same  man- 
ner as  above  laid  down. 


CHAPTER  VI. 

WOUNDS. 

A  WOTIXD  is  a  sudden  solution  of  continuity  in  one  or  more  of  the 
tissues  of  the  body.  By  common  consent,  such  lesions  in  bone  and  carti- 
lage are  called  fractures. 

Wounds  are  operative  and  accidental.,  and  may  be  classified  under 
four  leading  heads,  namely,  incised,  punctured.,  lacerated.,  and  contused. 
Any  breach  of  continuity  may  become  inoculated  with  a  virus,  or  venom  ; 
it  is  then  a  poisoned  wound. 

Perforating  injuries,  caused  by  missiles  projected  from  guns,  demand 
especial  consideration  as  gunshot  wounds.  An  incised  wound  is  made 
by  a  clean  cut  with  a  sharp  instrument.  A  punctured  wound  is  caused 
by  a  narrow  instrument  which  penetrates  but  does  not  cut  laterally.  A 
lacerated  wound  is  made  by  a  dull  instrument  which  tears  the  tissues. 
A  contused  wound  is  one  in  which  tlie  tissues  are  more  bruised  than 
separated. 

The  changes  which  occur  in  the  tissues  during  the  infliction  of  a 
wound,  and  in  the  process  of  repair,  are  as  follows  :  Take,  as  an  example, 
an  incised  wound  across  the  anterior  aspect  of  the  middle  of  the  thigh. 

As  the  section  is  made,  the  capillaries,  arterioles,  and  venules  within 
the  field  of  irritation  instantly  contract,  and  immediately  thereafter 
become  dilated.  With  the  impingement  of  the  knife  the  tissues  retract, 
and  haemorrhage  occurs.  The  wound  fills  with  blood,  and,  if  no  large 
vessels  are  divided,  the  bleeding  may  cease  spontaneously  by  coagulation. 
The  chief  factor  in  rapid  coagulation  after  a  wound  is  the  presence,  in 
increased  quantity,  of  the  white  corpuscles,  which  increase,  as  before 
stated,  always  takes  place  within  the  irritated  zone.  Under  the  abnormal 
conditions  present,  coagulation  results  from  a  combinaticm  of  the  para- 
glolnilin  of  the  leucocytes  with  the  fibrinogen  of  the  plasma.  This  pro- 
cess not  only  occurs  in  the  blood  extravasated,  but  extends  along  the 
capillaries  back  fi'om  the  edge  of  the  wound  to  the  nearest  anastomosis. 

Immediately  following  these  changes,  hypersemia.  redness,  swelling, 
heat,  and  pain  occur  in  the  edges  of  the  wound,  and  general  cell-prolifera- 
tion ensues,  as  described  in  the  preceding  chapter  on  Inflammation.  Xo 
repair  of  tissue  is  possible  without  this  inflammatory  process.  It  may 
be  mild  in  degree,  yet  it  must  of  necessity  exist.  A  reunion  of  atom  to 
atom,  capillary  to  capillary,  and  a  resumption  of  function  without  cell- 
proliferation,  can  not  occur. 
5 


06 


A  TEXT-BOOK   ON   SURGERY. 


If  the  edges  of  the  wound  have  not  been  approximated,  the  space  left 
by  the  separation  of  the  tissues  begins  to  be  tilled  in  a  few  days  with 
embryonic  or  granulation  tissue.  The  same  process  of  cell-proliferation 
oc('urs  iu  the  walls  of  the  wound,  and  extends  as  far  back  as  the  zone  of 
inllanimation.  The  most  essential  feature  of  the  earlier  process  of  repair 
is  the  new  formation  of  ca]iillaries,  upon  which  the  integrity  of  the  more 
advanced  embryonic  cells  depends. 

It  has  been  stated  that  not  only  the  white  blood-cells,  but  all  the 
stable  cells  of  a  part  involved  in  an  inflnmmntory  process,  take  a  more  or 
less  active  part  in  the  general  prolifin-ation  whicli  results  in  the  formation 
of  the  common  embryonic  tissue.  The  cells  of  the  capillarj'-walls  are 
among  the  first  to  take  part  in  this  general  ])roliferation.  The  new  tissue 
jn-ojects  in  minute  tufts  or  grauuhition  l)Uils  from  the  sides  and  bottoui 
of  the  wound.  In  this  tissue  the  line  of  capillaries  is  advancing  ;  Imt  in 
general  the  supply  of  nutrition  is  not  sufficient  to  maintain  the  vitality 
of  the  more  advanced  or  superficial  layers  of  cells,  and  these  may  perish 
by  a  process  of  granular  degeneration,  or.  If  more  suddenly  deprived  of 
the  necessary  quantity  of  l)lood,  by  gangrene,  more  or  less  limited.  Tlie 
dead  tissue  floats  off  in  the  liquor  purin. 

The  new  formation  of  capillaries  in  the  embryonic  tissue  of  a  wound 
undergoing  repair  may  occur  in  any  of  the  following  ways :  1.  From 
the  nearest  capillary  arch  or  loop,  one  or  more  vascular  buds  are  pro- 
jected into  the  embryonic  mass,  as  shown  in  Fig.  124.      The  contact 


Fig.  12-1.— (After  Paget.) 


Fig.  12.5.— (After  Paget.) 


and  fusion  of  these  buds  fonn  new  loops,  which  process  continues  until, 
as  the  process  of  repair  nears  completion,  the  arches  from  one  side  meet 
and  fuse  with  those  advancing  from  the  other,  and  thus  establish  direct 
communication  across  the  track  of  the  wound.  2.  It  is  also  jn-obable 
that  some  new  capillaries  are  foi-med  by  canalization  of  anastomosing 
cells,  a  process  analogous  to  the  formation  of  vascular  channels  iu  the 
normal  embryonic  tissue,  especially  in  those  parts  where  the  anastomos- 
ing plasmatic  cells  are  found.     3.  It  is  claimed  by  Eanvier  that  there  are 


WOUNDS. 


67 


developed  special  cells  for  vascular  new  formation,  which  he  has  called 
"  vessel-foi-ming  cells."  4.  By  escape  of  leucocytes  from  the  capillaries, 
these  emigrant  cells  invade  the  new  tissue,  passing  between  the  cells  of 
the  embryonic  protoplasm.  In  their  wake  the  red  corpuscles  and  liquor 
sanguinis  follow,  and,  by  pressure  upon  the  circumjacent  embryonic 
cells,  these  become  the  investing  membrane,  and  develop  into  the  capil- 
lary-wall (Fig.  125). 

With  the  establishment  of  a  capillary  system  in  the  granulation  tissue 
of  a  wound  the  process  of  conti-action  or  cicatrization  follows.  As  before 
stated,  some  of  the  embryonic  cells  undergo  fatty  degeneration  and  are 
absorbed,  or  die  and  are  washed  away  in  the  fluid  which  exudes  from  the 
surfaces  of  the  wound. 

Other  cells  develop  into  connective-tiscue  elements,  and  form  the  c(m- 
tracting  or  cicatricial  tissue  of  a  wound.     As  shown  in  Fig.  126,  the  first 


Fig.  126.— (After  Paget.) 


change  is  in  the  nucleus,  which  is  more  readily  defined,  assumes  an 
oval  shape,  and  shows  within  it  one  or  more  nucleoli.  The  cells  become 
granular  and  more  fusiform,  finally  changing  into  a  series  of  wavy 
bundles  of  connective  tissue  (Paget).  This  process  of  attenuation  or 
contraction  is  of  course  accompanied  by  obliteration  of  many  of  the  new- 
formed  capillaries,  and  a  more  than  normal  bleaching  of  the  cicatrix,  as 
is  frequently  observed  in  scars  upon  the  integument,  where,  although  the 
epithelium  is  reproduced,  the  hair  and  sebaceous  follicles  are  not  found. 

In  the  process  of  repair  in  some  wounds,  especially  in  those  which  are 
slight  and  are  subcutaneous,  or  are  thoroughly  cleansed  and  their  walls 
brought  and  held  in  apposition  by  well-sustained  pressure,  reunion  may 
be  secured  without  pus-formation,  with  great  rapidity,  and  without  any 
constitutional  disturbance.  Cell-proliferation  under  such  favorable  con- 
ditions is  limited,  the  process  more  nearly  physiological,  and,  while  many 
of  the  leucocytes  and  embryonic  cells  may  die,  the  mode  of  death  is  by 
granular  metamorphosis,  with  absorption  of  the  granular  matter.  Finally, 
all  wounds  heal  by  one  process  of  repair,  and  that  involves  inflammation 
and  cell-proliferation.  It  may  differ  in  degiee  of  intensity  as  the  injury 
is  more  or  less  severe,  or  as  the  tissues  implicated  are  in  a  condition  to 
resist  disease. 

Treatment.— The  arrest  of  hjrmorrhage  is  the  fii'st  indication.  Incised 
wounds  bleed  most  freely,  and  are  more  dangerous  in  this  particular  than 


68 


A  TEXT-BOOK   ON   SURCxERY. 


lacerated  and  contused  wounds.  In  one  the  vessels  are  smoothly  severed, 
in  the  other  the  ends  are  torn  in  shreds.  In  the  larger  vessels  retraction 
of  the  media  and  intima  occurs,  and  coagulation  is  more  readily  effected. 


Fio.  127.— (After  Esmarch.) 

Punctured  wounds  do  not  bleed  seriously 

unless  the  larger  vessels  are  opened.     On       ,,,„  i28.-Petit'8  sphai  tourniquet. 

account  of  the  extensive  lacerations  caused 

by  missiles  projected  from  guns,  the  same  may  be  said  of  wounds  of  this 

class. 

Haemorrhage  from  an  artery  should  be  controlled  by  pressure  over 
the  main  trunk,  between  the  wound  and  the  heart,  until  the  ends  of  the 


/  ^<^ 


Fio.  129. — Petit's  tourniquet  applied  in  the  brachial  and  femoral  arteries.     (After  Esmarch.) 

vessel   can  be  secured  with  the   catgut  ligature.      Venous  haemorrhage 
requires  the  elevation  of  a  part  (when  an  extremitj^  is  involved),  and 


WOUNDS. 


69 


pressure  upon  tlie  distal  side  of  the  wound  until  the  ligature  can  be 
applied  to  the  bleeding  point.  While  not  so  essential,  it  is  best  to  tie 
both  ends  of  a  divided  vein.     Direct  pressure  in  the  seat  of  a  wound  will 


Fig.  130.— (Alter  Esmarch.)        Fib.  ]31.— (After  Esmarch.) 


Fio.  132.— (After  Esmarch.) 


arrest  ordinary  haemorrhage.  AVhen  the  bleeding  is  from  an  extremity, 
an  emergency  tourniquet  may  be  made  by  tying  a  bridle-rein,  rope,  piece 
of  cloth  (as  the  leg  of  a  pair  of  trousers,  or  coat-sleeve),  or  any  other  sub- 
stance, around  the  part  above  the  wound,  and  twisting  this  by  means  of 


70 


A  TEXT-BOOK   ON   SURGERY. 


a  stick,  bayonet,  sword,  or  gun-barrel,  properly  inserted  (Fig.  127).  The 
efficiency  of  this  method  of  compression  is  increased  by  placing  a  pad 
over  the  main  artery.  Compression  of  an  artery  with  the  thumb  or  linger, 
or  a  padded  key  or  stick,  will  be  of  service  in  any  emorgcncy  where  a 
tourniquet  can  not  be  had. 

The  tourniquet  of  Petit  (Fig.  128)  is  one  of  the  older  and  more  useful 
instruments.     Its  application  is  illustrated  in  Fig.  129  («  and  h). 

EsmarcKs  elastic  bandage,  oi'  tourniquet,  is  the  most  generally  useful 
of  all  the  constricting  ha?mostatir  a])i)arutus.  It  may  be  thrown  around 
a  part,  between  the  bleeding  point  and  the  heart,  or  it  may  be  ai)i)licd 
from  the  tip  of  the  extremity,  and  over  and  on  the  cardiac  side  of  the 

wound,  and  here  se- 
cured, while  the  por- 
tion beyond  is  removed. 
In  this  waj^  the  limb 
is  rendered  bloodless 
(Figs.  130,  131,  132). 
This  excellent  appara- 
tus may  be  employed 
in  compression  of  the 
iliacs  (Fig.  133)  and  the 
abdominal  aorta  (Fig. 
134). 

When  the  immedi- 
ate flow  of  blood  is 
arrested  by  any  of  the 
foregoing,  the  perma- 
nent ari'est  of  ha?mor- 
rhage  must  be  secured 
by  the  ligature  at  the 
divided  point.  For 
this  purpose  theartery- 
forceps  and  the  catgut- 
ligature,  already  de- 
scribed, will  be  found 
by  far  the  most  pref- 
erable. Torsion  is  not 
as  safe  as  the  liga- 
ture, and  should  not  be 
employed  when  catgut  can  be  had.  The  advnl  cautery,  packing  with 
styptic  cotton,  and  acupressure  are  methods  never  to  be  employed  when 
anything  else  can  be  done.  If  a  wound  must  be  packed,  and  if  sublimate 
gauze  can  not  be  had  for  this  purpose,  use  clean  linen  or  cotton  cloth. 
Cold  water,  or  water  Jieated  to  about  120°  to  130°  F.,  will  prove  of  value 
as  a  haemostatic.  Elevation  of  a  part,  and  well-adjusted  compression  by 
dressing  and  bandage,  w^U  always  be  made  available  by  the  surgeon  of 
experience.  While  the  ligatures  are  being  applied,  and,  in  fact,  before 
this  time,  the  entire  surface  of  the  wound  should  be  inigated  with  1  to 


Fig.  133.— (After  Esmaroh.) 


Fig.  134.— (After  Esinarch.) 


WOUNDS.  71 

B,000  sublimate  solution,  and  thorou<;;lily  cleansed  of  all  clots  or  foreign 
matter.  Next  to  sublimate,  1  to  20  carbolic  acid  is  preferable,  and,  when 
neither  of  these  solutions  can  be  obtained,  the  purest  water  Hlioiild  be 
freely  used.  It  rarely  occurs  in  an  extensive  wound  tliat  all  hfeniorrliage 
can  be  stopped,  for  a  general  oozing  takes  place  from  capillai-ies  too 
numerous  to  tie.  H;pniorrhage  of  this  character  may  be  an-ested  by 
elevation  of  the  part,  or  pressure  either  by  approximation  of  the  walls 
of  the  wound,  by  packing,  or  by  general  compression  of  the  part 
with  a  l)andage.  If  the  edges  are  to  be  closed  with  sutures,  the  pack- 
inj,-  must  ))e  temporary.  It  is  most  successfully  practiced  by  crowding 
the  wound  full  of  sponges,  which  have  just  been  taken  out  of  a  basin 
of  hot  sublimate,  and  well  pressed  between  the  fingers.  A  hot  sub- 
limate towel  is  laid  over  these,  and  firm  pressure  made  for  about  five 
or  ten  minutes  with  the  hand  or  a  roller.  General  compression  of  a 
liuib  is  only  well  adapted  to  a  wound  which  has  been  made  or  cleansed 
under  Esmarch's  bandage.  After  the  important  vessels  are  secured, 
the  wound  is  closed,  drainage-tubes  inserted,  a  sublimate  gauze  dress- 
ing applied,  and  over  this  cotton  wadding  about  one  inch  in  thickness. 
A  layer  of  protective  is  placed  over  this,  and  the  necessary  pressure 
employed  by  means  of  an  ordinary  roller.  It  is  impossible  to  convey 
an  idea  of  the  amount  of  compression  to  be  used  in  applying  the  roller. 
It  should  be  tightly  drawn,  and  as  long  as  the  tips  of  the  toes  or  fingers 
are  left  out  for  constant  inspection,  so  that  any  arrest  of  the  circulation 
may  be  immediately  discovered,  no  danger  is  incurred. 

In  closing  a  wound  by  sutures,  the  points  of  chief  importance  are  to 
secure  drainage  and  to  bring  all  parts  of  the  oi)posiEg  surfaces  together 
with  equally  distributed  pressure.  A  wound  which  gapes  at  the  top  or 
bottom,  or  in  the  middle,  is  not  well  dressed.  As  for  drainage,  the 
material  for  which  has  been  already  discussed,  the  cardinal  law  is  that, 
in  the  position  in  which  the  part  must  rest  after  the  operation,  the  fiuids 
should  readily  gravitate  from  the  deepest  portion  of  the  wound  out  into 
the  dressings.  Before  approximating  wounded  surfaces,  if  laceratitms 
have  occurred,  the  shreds  of  tissue,  which  will  probably  slough,  should 
be  trimmed  oif  with  the  scissors,  and  the  walls  rendered  as  fresh  and 
smooth  as  circumstances  will  admit.  It  is  always  desirable  that  the  edges 
of  the  wound  in  the  skin  should  be  perfectly  smooth,  so  that  a  close 
adaptation  may  be  secured  and  an  ugly  scar  avoided.  This  is  esi)ecially 
essential  upon  the  face,  neck,  and  hands. 

In  closing  shallow  wounds,  or  those  of  not  more  than  one  or  two 
inches  in  depth,  it  will  usually  suffice  to  pass  the  needle  from  one  fourth 
to  one  half  of  an  inch  from  the  edge,  and  down  into  the  tissues,  so  tluit 
it  will  emerge  well  down  toward  the  bottom  of  the  wound.  It  should 
now  be  entered  in  the  opposite  wall  of  the  wound  at  the  same  dejith,  and 
brought  up  through  tlie  integument  at  a  point  corresponding  to  that 
where  the  needle  originally  entered.  When  a  suture  inserted  in  this 
manner  is  tied,  it  is  readily  seen  that  in  approximating  the  wounded 
surfaces  the  pressure  is  equally  distributed  at  the  surface  and  in  the 
deeper  portions.     When  important  vessels  and  nerves  are  in  i-elation  to 


72 


A   TP:  XT-BOOK  ON  SURGERY. 


the  walls  of  the  divided  tissues,  great  care  should  be  taken  to  avoid 
(nmslixing  these.  In  deeper  wounds,  an  initial  row  of  catgut  suture.s 
may  be  used  by  passing  the  curved  needle  into  the  tissues  of  the  two 
sides  well  below  the  integument,  and  tying  these  before  the  super- 
li(;ial  threads  are  inserted.  These  deep  sutures  are  rarely  necessary, 
however,  since  the  surfaces  may  be  held  in  apposition  by  the  bandag- 
ing. Of  the  various  forms  of  suture,  that  known  as  the  hitemipicd 
is  the  most  tiseful  and  satisfactory.  As  shown  in  Fig.  18i),  the  stitches 
may  all  be  on  the  same  plane,  or  there  may  be  a  wide  and  deep,  and 
an  intermediate  and  more  supcrlicial  row,  as  shown  in  Fig.  lIKi.  What- 
ever form  is  employed,  care  should  be  taken  tliaf  as  \\w  knot  is 
tightened  the  cutaneous  edg:'s  of  the  o]>posiiig  side  should  be  exaclly 
on  the  same  level.  In  order  to  effect  this,  it  is  often  necessary  to  lift 
one  side  with  a  director  or  liook,  or  depress  the  other  to  the  proper  level 
with  a  (lull  instrument.  No  fat  or  shred  of  tissue  should  be  allowed  to 
bulge  up  between  the  edges,  but  should  be  2)ushe(l  out  of  sight  with  a 
probe  or  forceps  while  the  suture  is  tied.  In  order  to  prevent  slipping, 
the  fiist  knot  shoidd  be  the  double  friclii)U-looi;)  (see  page  51),  which  is 


1/ 


"X 


■^  N 


Fici.    13(i. 


Fio.  135. 


Fio. 


the  only  one  that  will  hold  its  grip  while  the  sec(md  single  loop  is  being 
tied  to  secure  the  knot.  It  is  best  to  keep  the  knots  away  from  the  line 
of  the  approximated  edges.  In  tiglitening  the  sutures  the  effort  should 
be  made  to  bring  the  lips  of  the  wound  together  nicely  without  sullicieut 
tension  to  pucker  or  wrinkle  the  skin,  or  to  cau.se  it  to  be  infolded  or  to 
be  turned  white  from  too  mucli  pi-essure.  AVlien  expedition  rather  than 
nice  adjustment  is  desired,  the  cojitiniivus  suture  (Fio-  l-^'^)  rU'iy  l'^' 
practiced.  The  needle  is  always  passed  at  a  right  angle  to  the  axis  of 
the  wound,  although  that  part  of  the  suture  which  is  visilde  crosses  it 
of)liquely.  The  mattress  suture,  shown  in  Fig.  138,  and  the  quill  suture, 
at  Fig.  139,  are  practically  obsolete.  They  possess  no  advantages  which 
do  not  belong  to  the  intemtpted  or  rontiimous  methods. 

The  silrer-wire  suture  is  always  interrupted.     The  application  is  well 
shown  in  Fig.  140.     After  the  proper  apposition  is  secured  by  the  first 


WOUNDS. 


73 


twist,  made  with  the  fingers  down  at  the  level  of  the  skin,  the  ends 
should  be  clasped  in  an  artery-forceps  and  turned  eight  or  ten  times. 


Fig.  13S. 


Fig.  139. 


Fig.  140. 


The  pin-suture  is  still  popular  with  a  number  of  surgeons.  Silver 
l)ins,  or  the  ordinary  iron  pin  of  commerce,  may  be  employed,  and  the 
adjustment  of  the  opposing  surfaces  made  more  complete  by  throwing  a 
silk  or  catgut  interrupted  loop,  or  figure-of-8,  around  the  ends  of  the 
pin  (Fig.  141),  or  a  continuous  figure-of-8  applied,  as  shown  in  Figs.  142 
and  143. 


m 


^  hi  I  «■ 


Fig.  142, 


Fig.   143. 


t'l.^   Ul. 


Fig.   145. 


When  it  l)ecomes  necessary  to  close  a  three-cornered  wound,  a  cross- 
suture  (Fig.  144)  may  be  utilized,  or  the  double-needled  suture  (Fig.  145) 
may  be  substituted. 

Superficial  lesions  may  be  closed  by  adhesive  strips,  although  this 
method  is  less  exact  and  less  cleanly  than  the  sutures.  The  strips  should 
be  cut  narrow,  and  it  is  always  necessary  to  have  the  parts  to  which  they 
are  to  be  applied  dry  and  warm,  else  it  will  not  stick.  The  adhesive 
strips  hold  readily  when  warmed,  as  they  are  ap])lied,  or  when  moistened 
with  turpentine.     The  strips  may  be  dovetailed,  or,  while  the  edges  of 


74  A  TEXT-BOOK  ON  SURGERY. 

the  wound  are  held  in  apposition,  laid  directly  across  the  line  of  approxi- 
mation. 

Another  method,  less  frequently  employed,  yet  useful  at  times,  is  to 
take  a  i>iece  of  plaster  and  fasten  it  to  tlie  skin  parallel  with  the  edge  of 
the  wound.  A  half-inch  of  this  margin  is  folded  back,  and  to  this  hooks 
are  attached  and  elastic  threads  drawn  directly  across  or  in  figure-of-8 
fashion,  graduating  the  pressure  necessary  to  a  ]n'oper  apposition. 

The  needles  for  carrying  sutures  should  be  of  various  patterns,  and  of 
all  sizes,  for  different  purposes.  Some  are  straight  and  round,  ofln'is 
ai'e  lance  shai^ed  ;  scmie  should  be  crescentic,  others  straight  for  the  half 
or  two  thirds  of  the  shaft  nearest  the  eye,  and  curved  toward  the  ])oint. 
In  general  a  needle  should  not  cut  laterally  while  it  is  being  introduci'<I, 
since  the  lance-poiuti-d  variety  not  infrequently  causes  annoying  luemoi'- 
rhage  by  division  of  vessels,  which  the  round,  smooth  needles  would  push 
to  one  side. 

A  good  needle-holder  is  one  of  the  most  useful  instruments  <jf  the 
operator's  outfit.  It  should  have  a  handle  large  enough  to  be  well 
gras])pd  without  cramping  the  fingers,  and  strong  enough  to  stand  any 
required  force.  The  instrument  shown  in  Pig.  88  will  be  found  to  be 
very  satisfactory.  It  is  readily  locked  and  unlocked,  and  is  to  be  com- 
mended for  having  at  the  tip  a  copper  grip  for  curved  as  well  as  straight 
needles. 

After  the  wound  is  closed,  and  the  final  irrigation  made,  the  antiseptic 
dressing  heretofore  described  should  be  applied. 

When  liccmorrTiage  has  been  so  profuse  that  death  from  syncope  is 
imminent,  the  head  should  be  lowered  so  that  gravity  will  aid  the  How  of 
blood  to  the  brain  in  the  hope  of  maintaining  its  funt^tions.  The  admin- 
istration of  whisky  by  the  mouth  or  hypodermically  is  indicated.  If  the 
bleeding  is  occurring  internally,  an  elfort  must  be  made  to  confine  as 
much  blood  as  possible  in  the  extremities,  and  to  hold  it  there  until,  the 
pressure  at  the  bleeding-point  being  relieved,  stasis,  coagulation,  and 
arrest  occur.  This  method  I  have  i)racticed  in  several  serious  cases,  and 
have  seen  its  efficacy  demonstrated.  Both  arms  near  the  shoulder,  and 
both  thighs  six  inches  below  Poupart's  ligament,  are  constricted  l)y  towels, 
(cloths,  or  bandages  of  muslin  or  rubber,  which  are  tightened  just  enough 
to  retard  or  arrest  the  return  venous  circulation,  and  not  to  interfere 
with  the  outgoing  current  in  the  arteries.  In  this  way  several  pounds 
of  blood  may  be  held  away  from  the  bleeding-point  and  turned  into  the 
circulation  when  the  haemorrhage  ceases.  Care  must  be  taken  not  to 
produce  fatal  syncope  by  keeping  too  much  from  the  brain,  and  also  not 
to  return  too  much  of  the  pent-up  volume  into  the  circulation  at  once. 
Fluid  extract  of  ergot,  tti,  xxx,  hypodermically,  every  fifteen  minutes  until 
3  j  to  3  ij  doses  are  given,  is  one  of  the  best  medical  haemostatics.  If, 
despite  these  eiforts,  fatal  syncope  is  imminent,  tran^fus'on  is  imperative. 

The  proper  solution  is  :  Sodium  chloride,  gr.  x(dij ;  liquor  sodfc,  tti,  xx  ; 
aqure,  O  ij.  From  8  to  40  ounces  of  this  mixture  at  the  temperature  of 
the  blood  have  been  successfully  introduced.  This  simple  and  efficient 
method  of  transfusion  may  be  effected  through  a  vein  or  an  artery. 


WOUNDS. 


75 


Bisohoff  injected  3  xl  into  the  radial  artery  of  a  woman,  the  operation 
lasting  one  honr,  and  the  patient  recovered.  Szamann  and  many  other; 
luive  successfully  employed  this  method  by  injecting  into  a  vein.  In  a 
(^ase  in  the  practice  of  my  colleague,  Prof.  Munde,  I  introduced  5  viij 
through  the  median-cephalic  vein  within  ten  minutes.  This  quantity  was 
twice  repeated  in  twelve  hours.  The  ap- 
paratus I  employed  is  shown  in  Fig.  146. 
It  consists  of  a  funnel,  to  the  tip  of  which 
a  rubber  tube  is  attached.  To  the  end  of 
the  tube  is  a  canula  for  introduction  into 
the  vein.  Open  the  vein,  or  utilize  one  al- 
ready opened,  in  the  wound  if  this  is  pos- 
si!)Ie.  Warm  the  solution  to  aliout  100° 
F.,  fill  the  apparatus,  and  allow  a  small 
quantity  to  escape  tlirough  the  ]>ipette  in 
order  to  be  sure  that  no  air  is  introduced. 
If  then  the  stop-cock  is  turned,  or  the  rub- 
ber tube  compressed,  the  canula  will  be 
held  full  ot  fluid.  After  it  is  carried  into 
the  vein  it  shoidd  be  held  in  place  by  a 
ligature  tied  around  the  vessel  just  beliind 
the  expansion  at  the  nozzle.  If  the  stop- 
cock is  now  turned  on,  the  fluid  gravitates 
into  the  vein.  The  quantity  and  rapidity 
of  the  injection  may  be  regulated  by  press- 
ure upon  the  tube,  or  by  elevation  of  the 
funnel.  The  introduction  should  be  slow- 
ly and  gradually  accomplished.  Any  ordi- 
nary syringe,  if  thoroughly  cleansed,  may 
be  employed.  Care  should  always  be 
taken  to  prevent  the  introducticm  of  air. 
The  aspirator  heretofore  figured  is  an  ex- 
cellent instrument  for  transfusion  into  a 
vein  or  artery. 

The  older  methods  of  transfusion  with 
defibrinated  blood,  or  direct  transmission 
from  the  arm  of  the  giver  to  that  of  the  patient,  ai'e  now  completely 
superseded  by  the  saline  solution.  Successful  transfusion  of  simple 
water  at  the  temperature  of  the  blood  has  also  been  accomplished. 

Poisoucd  Wounds. — When  a,  venom  or  mrus  is  introduced  into  the 
tissues  through  a  solution  of  continuity,  it  is  called  a  poisoned  wound. 

Snake-Bite. — The  venom  of  certain  reptiles  carried  into  the  circulation 
through  a  wound  produces  alarming  and,  at  times,  fatal  results.  The 
intensity  of  its  action  is  in  pi-oportion  to  the  quality  and  quantity  of  the 
pois(m  absorbed,  as  well  as  to  the  rapidity  of  its  introduction.  Tlius,  the 
venom  of  the  cobra  and  rattlesnake  is  more  fatal  than  that  of  many 
other  fcn'ms.  Again,  the  venom  lodged  in  the  skin  and  subcutaneous 
areolar  tissues,  and  absorbed  by  the  lymph-vessels  and  caijiUaries,  is  far 


Fio.  141;. 


76  A  TEXT-BOOK  ON  SURGERY. 

less  potent  for  evil  than  that  which  is  injected  into  a  vein,  overwhelming 
the  lieart  and  sensorium  by  its  rapid  introduction. 

The  order  of  toxicity  in  serpent-venom,  so  far  as  known  at  this  date, 
is  as  follows  :  1.  Cobra  (Nala  tn'jjud/aiis),  a  native  of  India  ;  rattlesnake 
{Crotalus  durissus  and  C  adamanteus),  of  southern  North  America; 
Bothrop  jararacaKsa  and  B.  jararaca,  closely  allied,  aocordinfj  to  Dr. 
Robert  Fletcher,*  in  the  intensity  of  its  venom  to  its  congenei',  the  North 
American  rattlesnake  ;  American  copper-head  ( Trigonocephalus  contor- 
trlx) ;  the  American  moccasin  {I'oxleophif!  atrajiiscus  and  T.piscivorus) ; 
the  spreading  adder,  of  the  order  Vqjera  benis. 

The  venom  of  snakes  is  excreted  by  a  gland  situated  near  the  eye. 
In  the  act  of  striking  or  biting  it  is  forced  by  a  compressor  muscle  along 
a  channel,  or  groove,  in  the  fang.  In  the  quiescent  state  the  fangs  (one 
on  either  side)  are  folded  backward,  and  are  buried  in  grooves  in  the 
mucous  membrane  of  the  roof  of  the  moutli.  When  ready  for  nse,  they 
are  drawn  forward  by  erector  muscles.  Rattlesnake-venom,  according 
to  Dr.  S.  Weil-  Mitchell, f  has  a  specific  gravity  of  I'O-t-t,  and  an  invariably 
acid  reaction.  Its  color  is  from  a  greenish  to  a  straw  tint.  Conjointly 
with  Dr.  Edward  T.  Reichert,^  lie  has  isolated  three  proteids— namely, 
venom-peptone,  venom-globulin,  and  venom-albumen.  Venom-globulin 
is  intensely  toxic,  producing  rapid  extravasations  of  blood  ;  venom-pep- 
tone is  less  poisonous,  but  produces,  when  injected  into  the  breasts  of 
pigeons,  intense  sloughing.  The  albumen-venom  is  not  vet  fullv  under- 
stood.  Bromine,  iodine,  sodium,  and  potassium  hydrate  and  potassium 
permanganate  destroy  chemically  the  toxic  property  of  the  venom  of  the 
rattlesnake,  copper-head,  and  moccasin.  Serpent  -  venom  produces  no 
poisonous  effect  in  the  tissues  of  the  reptUe  which  produces  it,  or  in  the 
tissues  of  any  venom-producing  reptile. 

As  just  stated,  the  symptoms  resulting  from  snake -bite  in  man 
vary  with  the  toxicity  of  the  venom,  the  amount  introduced,  and  with 
the  rapidity  with  which  it  is  carried  into  the  circulation.  A  keeper  in 
the  London  Zoological  Grardens  was  bitten  on  the  nose  by  a  cobra,  and 
died  in  a  little  more  than  one  hour.*  Dr.  Wainwright,  of  New  York 
city,  died  ^vithin  six  hours  after  being  bitten  l)y  a  rattlesnake.  |[  Dr.  G. 
A.  Kunkler  ^  reports  the  case  of  a  boy  six  years  old,  who  died  during  a 
convulsion  on  the  fourth  day,  after  being  bitten  on  the  foot  by  a  copper- 
head. The  venom  is  seemingly  as  potent  in  cold  as  in  warm  weather. 
Dr.  E.  P.  King  ^  treated  a  patient  in  whom  well-marked  toxic  symptoms 
were  developed  after  being  bitten  by  a  copper-head  which,  although 
torpid,  had  recovered  its  activity  under  the  influence  of  heat.    When  the 

*  "  American  Journal  of  the  Medical  Sciences,"  July,  1883. 

t  Smithsonian  Contributions,  1860.     "New  Yorlc  Medical  Journal,"  1868. 
+  '-Philadelphia  Medical  Xews,"  1883. 

*  Bryant's  •'  Surgery." 

J  Hamilton's  '■  Surgery." 

•^  "Cincinnati  Lancet  and  Observer,"  1859.  '•  Americran  Journal  of  the  Medical  Sciences," 
April,  1883. 

0  "American  Journal  of  the  Medical  Sciences,"  April,  1884,  p.  428. 


WOUNDS.  77 

clothing  intervenes,  the  venom  is  likely  to  be  in  part  arrested,  and  the 
effect  less  severe. 

Pain  of  a  sharp  or  stinging  character  is  usually  felt  in  the  wound. 
Fright  or  shock  may  mask  this  symptom.  Swelling  rajiidly  ensues,  and 
in  rattlesnake-bite  ecchymosis  is  not  uncommon.  The  swelling  extends 
in  all  directions,  but  is  most  marked  in  the  line  of  the  lymphatics  toward 
the  center.  Headache,  fever,  rigors,  irregular  breathing,  and  a  low,  fee- 
ble pulse,  with  nausea,  may  be  present.  Adenitis,  abscess,  or  sloughing 
usually  occur.  If  death  does  not  ensue,  the  case  may  terminate  favor- 
ably in  two  or  three  days,  or  last  for  weeks  and  months. 

Treatment. — The  immediate  indication  is  the  removal  of  the  venom. 
Labial  suction  is  an  efficient  method,  and  may  be  safely  practiced,  pro- 
vided that  there  is  no  abrasion  on  the  lips  or  contiguous  mucous  sur- 
faces. Inoculation  is  more  dangerous  about  the  mouth  and  neck  than 
elsewhere,  since  the  great  swelling  may  close  the  trachea  or  larynx. 
Next  in  order  of  readiness  is  free  and  immediate  excision  of  the  tissues 
within  a  radius  of  half  or  three  fourths  of  an  inch  from  the  puncture, 
or  free  incisions  may  be  made  so  that  the  flow  of  blood  may  wash  the 
venom  out. 

Permanganate  of  potassium  is  probably  the  best  chemical,  and  whisky 
(or  alcohol  in  some  other  form)  the  best  physiological  antidote.  Dr.  de 
Lacerda,*  of  Brazil,  recommends  the  immediate  injection  in  and  around 
the  wound  of  a  1-per-cent  (gr.  v  to  3  j)  solution  of  the  permanganate  in 
water,  and  also  an  intra-venous  injection  if  the  venom  has  had  time  to 
enter  the  circulation.  Dr.  Robert  Fletcher  f  states  that  Richards,  of  Cal- 
cutta, after  repeating  Lacerda's  experiments,  recommends  a  o-per-cent 
solution  in  cobra-poison  ;  3  j  to  "  iv  of  a  solution,  varying  from  gr.  v  to 
gr.  X  to  water  5  j,  would  lie  aljout  the  safest  treatment  for  rattlesnake- 
venom  ;  and  the  weaker  solutions  for  coj^per-head  and  moccasin  bites.  It 
must  not  be  forgotten  that  this  salt  is  toxic  in  overdoses.  Vulpian  pro- 
duced death  in  a  small  dog  with  an  injection  of  gr.  vij.  Whisky,  or  any 
form  of  alcohoJ,  is  a  favorite  cardiac  stimulant,  and  may  be  taken  in 
adults  in  large  quantities  without  intoxication.  Care  must  be  taken  in 
administering  alcohol  to  children,  since  it  has  occasionally  proved  fatal. 

When  great  swelling  occurs,  and  gangrene  is  threatened  on  account 
of  tension,  free  incisions  or  punctures  should  be  made. 

The  venom  of  some  of  the  lizard  family,  as  the  Gila  monster:}:  {Helo- 
derma  suspect  urn)  and  the  toad**  {Bu/o  Tidgaris),  also  possesses  toxic 
jjroperties.  The  treatment  should  be  about  the  same  as  given  above  for 
serpent- venom,  though  not  quite  so  energetic. 

Venom  introduced  with  the  sting  of  the  scorpion  not  infrequently 
causes  death  in  the  Orient,  although  the  sting  of  the  Xorth  American 
scorpion  is  not  dangerous.     I  have  failed  to  hear  of  a  death  fi-om  this 

*  "  Gazette  des  h6pitaux;"  1881,  pp.  597  and  891.    Also,  a  valuable  paper  by  Dr.  H.  C.  Yar- 
row, "  Anieriean  -Journal  of  the  Medical  Sciences,"  April,  1S84. 
t  "American  -Journal  of  the  Medical  Sciences,"  July,  1883. 
t  Mitcliell  and  Roichert.  "  Medical  News,"  Philadelphia,  1883. 
»  "  Gazette  des  bopitaux,"  1881,  p.  598. 


78  A  TEXT-BOOK   ON   SURGERY. 

accident,  although  I  have  made  personal  inquiry  from  numerous  prac- 
titioners in  the  South  and  West,  who  have  had  much  experience  with 
these  cases.  In  a  personal  experience,  in  which  T  was  stun<i;  by  a  scoi' 
pion  in  the  palm  of  the  hand,  no  unpleasant  symptom  followed.  As  soon 
as  the  insect  was  brushed  oflf,  the  venom  was  removed  by  sucking  the 
wound,  and  by  expression. 

The  venom  of  the  tarantula,  and  other  spiders,  is  occasionally  fatal. 
In  a  private  communication.  Dr.  Thomas  A.  Pope,  of  Texas,  who  has  seen 
many  cases  of  tarantula-bite,  reports  one  fatal  case.  Death  did  not  ensue, 
however,  from  the  changes  induced  in  the  blood  by  the  venom,  but  from 
asphyxia  due  to  closure  of  the  larynx  and  trachea  from  great  swelling, 
the  man  having  been  bitten  in  the  neck. 

The  swelling  is  usually  severe,  and  an  erythematous  rash  occurs  about 
the  second  day.  This  may  occupy  one  half  or  all  of  the  body.  Slougii- 
ing  at  the  wound  almo.st  always  occurs. 

The  stings  of  bees,  wasjjs,  Jiornets,  etc.,  possess  a  venom  Avhich.  while 
rarely  fatal,  is  painful  and  annoying.  The  application  of  an  alkaline 
solution  will,  if  immediately  used,  neutralize  the  pain  and  the  tendency 
to  swelling.  Clay  moistened  into  a  paste  with  the  saliva  is  an  effective 
remedy  used  by  the  negroes  in  the  Southern  States.  The  sting  should  be 
removed  if  it  has  remained  in  the  wound.  In  the  case  of  a  negro  child, 
three  years  old,  who  had  just  a  miniite  or  two  before  been  stung  by  about 
forty  bees,  no  serious  symptom  ensued.  The  treatment  followed  was 
brushing  the  insects  off  with  a  sheet,  and  thoroughly  sponging  the  entire 
body  with  a  solution  of  a  teacupful  of  ordinary  saleratus  in  two  quarts  of 
water. 

The  venom  of  the  centipede  scarcely  deserves  mention.  I  am  told  by 
physicians  practicing  in  the  sections  infested  by  these  Myriapndn  that 
their  toxic  power  is  much  exaggerated.  The  slight  effects  which  follow 
their  foot-marks  and  the  bite  of  the  tarantula  should  be  treated  by  per- 
raangana'^e  of  potassium  locally  and  stimulants  internally. 

Hydrophobia. — The  bite  of  certain  animals,  as  the  wolf,  dog,  fox,  and 
cat,  is  at  times  followed  by  alarming,  and  often  fatal  sjTuptoms,  due  to 
the  absorption  of  a  specific  virus.  It  was  formerly  thought  that  the 
saliva  alone  was  tne  menstruum  for  this  poison,  but  Pasteur*  has  recently 
claimed  that  he  has  produced  rabies  in  animals  inoculated  with  the 
cephalo-rachidian  fluid,  and  the  nerve-matter  of  the  medulla  oblongata 
of  other  animals  suffering  from  this  disease.  He  also  claims  that  by 
successive  cultures  of  the  specific  germ  of  this  disea.se,  and  inoculations 
with  the  cultures,  immunity  from  rabies  may  be  secured.  While  any 
statement  from  this  gi-eat  scientist  is  entitled  to  credence — and  while  the 
report  of  the  commission  appointed  by  the  French  Government  fully 
proves  the  success  of  Pasteur's  method  in  animals — it  is  not  yet  fully 
determined  that  vaccination  will  give  immunity  to  man,  nor  prevent  the 
development  of  rabies  after  inoculation. 

Hydrophobia  may  follow  the  bite  of  an  animal  seemingly  in  perfect 

*  "Gazette  des  h6pitanx,"  1881,  p.  502.    rbii.,  1884,  p.  733. 


WOUXDS.  79 

health,  as  well  as  from  one  noticeably  affected  with  rabies.  In  man  and 
other  animals  it  may  occur  at  any  season  of  the  year,  and  in  all  climes. 
The  wound  inflicted  always  heals  slowly,  even  without  regard  to  the 
inoculation  of  the  specific  virus,  for,  in  addition  to  being  contused  and 
lacerated,  it  is  infected  by  contact  with  the  saliva,  which  even  in  man 
Sternberg*  has  shown  will  produce  fatal  sepsis  when  injected  into  the 
tissues  of  animals. 

The  period  of  incubation  in  rabies  in  man  varies  from  five  days  to  as 
many  months,  and  in  exceptional  instances  to  as  long  as  one  or  two 
years.  The  symptoms  of  its  approach  are  often  vague.  Pain  in  the 
track  of  the  sensory  nerves  leading  from  tlie  wound,  and  in  and  about 
the  wound  or  scar,  is  given  as  among  the  earlier  indications.  Irregular 
heart-action  occurs,  together  with  respiratory  disturbance  of  a  convulsive 
character.  The  face  expresses  a  sense  of  actual  suffering,  or  of  anxiety 
in  the  anticipation  of  impending  disaster.  Nausea,  increased  flow  of 
saliva,  and  vomiting  occur,  and  often  are  followed  by  genei-al  or  partial 
convulsive  movements.  Death  ensues  usually  between  the  second  and  fifth 
day.  Prof.  Flint t  is  of  the  opinion  that  no  well-authenticated  case  has 
ended  in  recovery.  In  three  out  of  seven  cases  examined  by  Southam:}: 
sugar  was  present  in  the  urine,  which  fact  indicates  irritation  of  the 
medulla,  and  is  coiToborative  of  Pasteur's*  statement  that  the  gray  mat- 
ter of  the  brain  and  cord,  and  especially  the  medulla  oblongata,  is  affected 
by  the  poison  (microbes)  of  rabies. 

Treatment. — Preventive  measures  are  of  first  importance.  If  Pasteur 
is  correct  in  his  deductions — and  there  is  little  doubt  of  his  success  with 
animals — enforced  inoculation  (vaccination)  of  all  dogs  and  cats  should  be 
l)racticed.  The  wound  inflicted  by  any  animal,  and  especially  one  either 
suspected  or  known  to  be  suffering  from  rabies,  should  be  immediately 
and  freely  excised,  or  the  parts  in  and  around  the  wound  destroyed 
by  the  actual  cautery,  or  by  a  penetrating  escharotic.  When  situated 
upon  a  part  of  the  liody  wliich  can  be  brought  in  contact  ^^itll  the  mouth, 
the  blood,  and  with  it  the  virus,  may  be  removed  by  labial  suction.  After 
absorption  has  occurred,  and  with  the  appearance  of  the  convulsive  stage, 
chloral  hydrate  and  opium  by  the  stomach,  and  chloroform  or  ether  by 
inhalation,  may  be  given,  as  required.  Cannabis  Indica  is  reported  as 
successful  in  a  single  case.|| 

Glanders. — This  name  has  been  given  to  a  contagious  disease  which 
attacks  animals,  chiefly  horses,  and  is  communicated  to  man  by  inocu- 
lation of  the  peculiar  vii'us  ui)on  a  mucous  membrane  or  a  cutaneous 
wound.  In  horses  the  mucous  membranes  of  the  throat  and  nose  are  first 
affected,  and  this  is  followed  by  enlargement  and  breaking  down  of  the 
lymphatic  glands  of  the  neck,  and  by  symptoms  of  general  sepsis,  meta- 
static abscesses,  and  cutaneous  ulcers.    It  is  not  only  communicable  from 

*  "  .American  Journal  of  the  Medical  Sciences,"  1882,  p.  69. 
t  Flint's  '•  Practice  of  Medicine." 

X  "  Medical  Record,"  vol.  xsi,  p.  128. 

*  Loc.  cit. 

\  "Medical  Record,"  vol.  xxi.  \>.  179. 


80  A  TEXT-BOOK   ON  SURGERY. 

au  animal  to  man,  but  from  one  person  to  another.  Schutz  and  Loftier, 
in  Koch's  laboratory,  have  recently  announced  the  discovery  of  the  bacil- 
lus of  glanders,  which  is  said  to  resemlile  the  bacillus  tuberculosis. 
These  organivsms  were  seen  by  WassilielT  in  the  blood  of  a  man  sick  with 
this  disease.  Inoculated  with  this  virus,  the  parts  about  a  wound  become 
ra])idly  inftanied  and  swollen.  Cellulitis,  lymphangitis,  and  adenitis 
ensue,  with  high  febrile  movement  and  the  usual  ccjuditious  of  septi- 
c;emia.  Inoculated  upon  a  mucous  surface,  the  morbid  process  is  prac- 
tically the  same.  The  inflanmiation  spreads  rapidly,  and  the  adenitis 
and  ulcerations  occur  in  man  as  in  animals.  In  severe  cases  metastatic 
nodules  occur  in  the  skin,  not  infrequently  breaking  down  into  pustules. 
Abscesses  may  be  general.     In  the  severer  cases  death  is  the  rule. 

The  indications  in  treatment  are  to  support  the  tissues  by  all  possible 
measures  of  nutrition.  A  wound  freshly  inoculated  should  be  treated  as 
advised  in  rabies. 

3falir/nan,t  Pustule. — This  disease  in  man  results  from  the  inoculation 
of  a  peculiar  virus  which  is  found  in  the  tissues  of  animals  infected  \A-ith 

a  micro-organism,  the  antlirax  bacillus  (Fig.  147). 
This  bacillus  is  believed  to  be  the  disease-germ. 
Carnivora  are  rarely  susceptible.  The  virus  is 
intensely  toxic,  and  exceedingly  contagious.  By 
some  it  is  held  that  an  abrasion  of  the  integument 
or  mucous  surfaces  is  not  always  necessary  to  the 
invasion  of  the  germ.*  The  bite  of  an  insect  which 
has  been  feeding  upon  anthrax  carrion,  or  the  in- 
gestion of  infected  meat,  or  the  mere  contact  with 
Fig.  147.— (After  Sternberg.)     the  hair.  Wool,   bones,  or  any  part  of  an  animal 

dead  with  anthrax,  is  dangerous.f  Tanners,  butch- 
ers, and  fun'iers  are  more  often  the  sufferers  from  this  disease  than  oth- 
ers. The  virus  retains  its  potency  almost  indefinitely.  Sheep  allowed  to 
graze  in  localities  where  carcasses  of  cattle  dead  with  anthrax  have  been 
buried  many  years  acquii'e  the  disease  by  ingestion  of  germs  lodged  upon 
the  grass,  and  in  the  earth  over  these  graves.  Contagious  from  animal 
to  animal,  and  from  animal  to  man,  it  is  likewise  contagious  from  one  in- 
dividual to  another.  The  face  aud  hands  are,  on  account  of  exposure, 
most  frequently  the  seat  of  the  inoculation.  The  symptoms  are  redness, 
swelling,  induration,  a  throbbing  sensation  and  pain  at  the  point  of 
contact  of  the  virus.  AVithin  twenty-four  hours  an  ulcer  usually  is  de- 
veloped in  the  center  of  the  indurated  area,  soon  followed  by  lymphan- 
gitis and  adenitis.  High  temperature,  rapid  pulse,  headache,  nausea, 
and  the  usual  condition  of  general  septicjemia,  foUow  as  the  disease  pro- 
gresses. 

Microscopical  research  has  demonstrated  bacilli,  in  great  numbers, 
not  only  in  the  tissues  immediately  around  the  seat  of  contagion,  but,  also 
in  the  later  stages  of  the  disease,  a  general  dissemination  of  these  organ- 

*  Afmew's  "  Snrjrery,"  vol.  i,  p.  214. 

t  "  New  York  Medical  Journal,"  1884,  p.  410. 


WOUNDS.  81 

isms.  Hfemorrhagic  infarctions  and  ceclema  are  frequent  symptoms. 
When  the  disease  results  from  the  ingestion  of  the  poison,  the  diagnosis 
is  difficult.  Swelling  and  puffiness  of  the  face  have  been  observed,  vrith 
high  febrile  movement  and  great  prostration. 

Treatment. — Local  and  constitutional  measures  are  demanded — ex- 
cision or  free  incision,  and  the  application  of  a  strong  sublimate  solution 
(1  to  1,01)0).  Supporting  measures  are  demanded  when  the  infection  is 
general  and  prostration  is  threatened. 

Dlxscrfion  Wounds. — A  wound  is  not  apt  to  become  poisoned  from 
contact  with  the  tissues  of  a  cadaver  which  has  been  thoroughly  injected 
with  chloride  of  zinc,  arseniate  of  soda,  or  sublimate  solution.  Septic 
matter  from  non- injected  subjects  is  always  a  source  of  danger  when 
brought  in  contact  with  abrasions  of  the  skin  or  mucous  surfaces.  The 
contents  of  the  peritoneal  and  pleural  cavities  are  especially  virulent. 
The  fluids  from  persons  dead  from  any  septic  or  malignant  disease,  such 
as  erysipelas,  small-pox,  etc.,  are  unusually  dangerous.  Patients  suffering 
from  suppurative  arthritis,  with  general  sepsis,  are  dangerous  subjects. 
In  a  recent  case  of  this  nature  in  IMount  Sinai  Hospital,  a  colleague  and 
one  member  of  the  house-staff  and  the  nurse  were  all  seriously  inoculated 
from  the  same  operation.  Susceptibility  varies  with  the  individual. 
Some  enjoy  lasting  immunity  under  all  conditions  of  exposure,  while 
others  are  easily  inoculated. 

Symptoms. — Intiammation  and  soreness  at  the  wound  are  first  noticed. 
In  a  few  days  lines  of  redness  extend  in  the  route  of  the  lymphatics,  and 
the  arm  (since  the  hand  is  usually  the  seat  of  the  primary  lesion)  becomes 
painful,  stiff",  and  hot.  The  epitrochlear  and  axillary  glands  enlarge,  and 
in  many  cases  suppurate.  Rigors,  fever,  headache,  aching  of  the  joints, 
coated  tongue,  and  other  symptoms  of  sepsis  follow.  The  jwtient  may 
pass  into  a  low  tyjDhoid  state,  or  general  metastatic  abscesses  may  occur, 
ending  in  death. 

Treatment. — Ablution  of  the  wound  in  sublimate  solution  fl  to  .'lOO) 
and  suction  should  be  instantly  performed,  or  suction  alone  may  remove 
the  poison.  It  should  be  kept  open  and  washed  frequently.  Cold 
cloths  or  the  ice-bag  will  be  found  very  grateful  in  the  lymphangitis  and 
adenitis  which  follow  the  inoculation.  Caustics,  or  coveiing  in  an  abra- 
sion with  liquor  gutta- perch ?e,  collodion,  or  plaster  (except  for  protec- 
tion against  further  inoculation),  is  an  absurd  and  dangerous  practice. 
If  abscesses  form,  early  incision  is  demanded.  The  constitutional  reme- 
dies are  quinia,  tonics,  stimulants,  antipyrine,  judicious  feeding,  and 
ventilation. 

Erysipelas. — Erysipelas  is  a  contagious  as  well  as  an  infectious  dis- 
ease, caused  by  tlie  invasion  through  an  abrasion  of  the  integument,  or 
by  the  mucous  surfaces,  of  a  specific  poison  or  virus.  The  presence  of 
an  almost  constant  micrococcus  in  the  inflammatory  area  of  erysipelas 
has  led  some  obsen-ers  to  ciuisider  this  organism  as  the  cause  of  the 
disease ;  but  the  fact  that  it  has  been  wanting  in  some  instances  ex- 
amined by  careful  investigators  would  seem  to  disprove  this  theory.  It 
may  spread  from  one  infected  person  directly  to  another,  or  indirectly 


82  A  TEXT-BOOK  ON   SURGERY. 

by  means  of  the  clothing  or  hands  of  an  intennediate  party.  It  is  char- 
acterized by  an  inflammation  of  the  skin  or  mucous  surfaces,  of  the  sub- 
cutaneous and  submucous  tissues,  and  at  times,  passing  the  liarrier  of 
the  deep  fascia,  it  attacks  tlie  nuiscles  and  deeper  organs.  The  period 
of  incubation  varies  from  eight  to  twelve  hours  to  three  or  four  days. 
For  constitutional  or  even  marked  local  symptoms  to  occur  within  twenty- 
four  hours,  however,  after  exposure  of  a  wound  to  the  virus,  is  the  excep- 
tion rather  than  the  rule.  In  the  large  majority  of  cases  the  symptoms 
declare  themselves  usually  between  twenty-four  and  forty-eight  hours. 
Locally  the  part  becomes  hot,  throbbing,  tense,  and  painful,  csijccially 
on  direct  pressure.  The  color  varies  from  a  pale  rose  to  a  luight  red 
hue.  In  well  marked  cases  the  inflamed  integument  ajijiears  to  be 
glazed,  and  tlie  limit  of  redness  is  regularly  and  sharply  deliiit-d.  Wlien 
the  inflammatory  process  is  rapid,  and  the  integrity  of  tlu»  circulation 
markeilly  iinpaired,  the  bright  flush  of  the  skin  gives  way  to  a  dull 
mottled  discoloration.  Pressed  by  the  tip  of  the  flnger,  the  skin  becomes 
pale,  but  the  color  returns  and  the  indentation  is  soon  effaced,  except  in 
those  cases  of  marked  oedema.  Lym]ihnngitis  and  occasionally  ])hle- 
bitis  occur.  The  spread  of  these  complications  is  indicated  by  lines  of 
redness  and  tenderness  leading  in  the  route  of  these  vessels.  In  some 
instances  vesicles  or  bulla;  form  beneath  the  epidermis.  An  attack  of 
erysipelas  is  almost  always  ushered  in  by  one  or  more  chills,  or  by  dif- 
ferent and  recurring  chilly  sensations  or  rigors.  The  exacerbation  of 
temperature  varies  from  100°  to  104'  or  105°  F.  The  pulse  is  propor- 
tionately increased  in  frequency.  The  febrile  movement  and  constitu- 
tional symptoms  vary  with  the  character  of  the  attack.  In  simple 
cutaneous  ei-ysipelas  the  clinical  history  is  usually  mild.  In  the  ceUiiIo- 
ciitaneous  or  phlegmonovs  variety  severe  and  fatal  sepsis  is  not  uncom- 
mon. Gangrene  is  occasionally  met  with  alwut  the  center  of  the  in- 
flamed zone,  and,  when  attacking  an  extremity,  the  circulation  may  be 
an-ested  and  the  part  beyond  the  disease  sacrificed.  The  duration  may 
be  from  seven  to  ten  days  in  mild  cases  to  several  weeks  in  the  severer 
and  not  fatal  forms. 

BldfinoHifi. — Erysipelas,  within  the  first  twenty-four  or  forty-eight 
hours  of  its  appearance,  may  be  taken  for  dermatitis,  or  simple  erythema, 
phlebitis,  lymphangitis,  or  cellulo-dermatitis. 

Dermatitis  occurs,  as  a  rule,  from  local  irritation,  and  is  not  accom- 
panied by  any  of  the  constitutional  disturbances  which  always  occur  with 
erysipelas.  In  simple  inflammation  of  the  skin  the  color  is  red,  Imt  it 
never  has  the  glazed  appearance  which  is  always  i>resent  in  a  typical 
erysipelas.  Erythema,  a  mild  foi-m  of  dermatitis,  may  also  be  mistaken 
for  erysipelas.  In  erythema  papiilatum  the  exposed  and  extensor  sur- 
faces, as  the  dorsum  of  the  hand  and  the  posterior  aspect  of  the  forearm, 
are  apt  to  be  involved.  There  is  no  wound  of  inoculation ;  very  slight,  if 
any,  infiltration  of  the  skin  proper.  Children  and  younger  adults  suffer 
most  frequently.  It  lasts  for  only  a  few  days,  then  fades  away,  leaving 
a  dry  scale  to  indicate  the  location  of  the  papule.  Omng  to  the  various 
shapes  and  the  different  shades  of  color  assumed  by  the  papules,  and 


WOUXDS.  83 

efflorescence  of  the  erythema,  it  has  been  divided  into  erythema  annu- 
lare^ erythema  gyratum,  and  erythema  iris.* 

In  erytliema  intertrigo  there  is  a  general  redness  of  the  skin  in  parts 
subjected  to  friction  or  irritation  from  persj)iration.  Erythema  nodo- 
sum is  almost  peculiar  to  chlorotic  females.  The  color,  at  first  bright 
red,  soon  changes  to  a  dark  hue.  The  patches  are  oval,  elevated,  and 
nodular. 

Phlebitis  and  lymphangitis  are  more  severe  forms  of  inflammation 
tlian  those  just  given,  and  are  accompanied  with  constitutional  symptoms 
not  unlike  those  present  in  a  typical  erysipelas.  The  chief  point  of  diag- 
nostic value  relates  to  the  anatomical  arrangement  of  the  vessels,  for  in 
phlebitis  and  lymphangitis  the  lines  of  inflammation  and  discoloration 
travel  along  the  course  of  tlie  vessels  without  the  general  and  wide-spread 
efflorescence  of  erysipelas. 

Diffuse  cellulitis  occtirring  from  a  poisoned  wound,  as  with  a  dissect- 
ing-knife,  or  after  the  bite  of  a  serpent,  will  offer  no  difficulty  in  diagnosis. 
It  may,  however,  occur  without  a  recognized  cause.  The  subcutaneous 
tissues  are  first  attacked,  and  the  skin  may  or  may  not  be  involved  in  the 
process  of  inflammation.  There  is  swelling  and  painful  tension  of  the 
part  affected,  and,  if  the  process  be  uninterrupted,  transudation  of  serum 
occurs,  causing  oedema,  and  giving  a  doughy  feeling  on  pressure.  Pus 
may  be  formed  in  quantity,  and  infiltration  become  extensive.  This 
result  is  more  apt  to  occur  in  ditt'use  non-specific  cellulitis  than  in 
phlegmonous  erysipelas.  This  condition,  especially  when  the  skin  be- 
comes invi>lved,  offers  considerable  difficulty  to  a  positive  diagnosis.  If, 
however,  the  peculiar  symptoms  heretofore  given  be  carefully  considered, 
and  a  comparison  instituted  between  them  and  the  phenomena  of  the 
various  diseases  which  may  simulate  or  complicate  erysipelas,  it  will  be 
found  that,  in  the  great  majority  of  cases,  a  correct  diagnosis  may^  be 
made. 

Prognosis. — Simple  cutaneous  erysipelas,  as  a  rule,  is  not  a  dangerous 
disease.  In  several  epidemics  in  hospital  i^ractice  I  have  never  seen  a 
fatal  case.  Occurring  about  the  face,  head,  or  neck,  the  prognosis  is  less 
favorable  than  when  the  inoculation  occurs  elsewhere.  When  it  compli- 
cates a  wound  in  a  patient  already  prostrated  by  haemorrhage  or  surgical 
fever,  it  may  hasten  a  fatal  issue.  In  phlegmonous  or  cellulo-cutaneous 
erysipelas  the  prognosis  is  not  so  favorable.  Suppuration  and  the  general 
infiltration  of  the  tissues  with  pus  and  inflammatory  products  induce  a 
condition  of  septicaemia  often  rapidly  fatal. 

Treatment. — In  an  outbreak  of  erysipelas  the  treatment  in  those 
attacked  is  both  local  and  constitutional,  while  in  others  strict  measures 
of  prophylaxis  should  be  instituted.  Immediate  isolation  should  be 
effected,  and  the  gi-eatest  care  observed  to  prevent  contact  with  other 
subjects.  All  bedding,  furniture,  and  apparatus  nsed  upon  or  about  an 
erysipelatous  patient  should  be  burned,  or  thoroughly  scrubbed  and 
soaked  in  a  solution  of  corrosive  sublimate  varying  in  strength  from  1  to 

*  Neumann,  '■  Hand-Book  of  Skin  Diseases."    Bulkley.    D.  Appleton  &  Co.,  18V2. 


84  A  TEXT-BOOK  ON  SURGERY. 

500  to  1  to  1,000.  Any  instrument  subjected  to  contamination  shoixld  be 
submerged  in  1  to  10  to  1  to  20  carbolic  a('id,  and  afterward  tlioi'oughly 
dried.  The  walls  and  floors  of  a  ward  or  room  in  which  an  outbreak  has 
occurred  should  be  moi:)ped  and  washed  in  the  sublimate  solution.  The 
attendants  upon  such  cases  should  be  excluded  from  all  possible  contact 
with  other  individuals.  When  a  physician  is  compelled  to  visit  a  case  of 
erysipelas,  he  should  wear  clothing  which  should  be  changed  immediately 
after  leaving  the  room,  which  precaution  should  be  emphasized  by  a 
thorough  disinfection  of  his  hands,  face,  beard,  and  hair  in  1  to  3,000 
sublimate  solution.  The  local  measures  always  include  ;is  of  iirst  inqtor- 
tance  the  investment  of  the  part  involved  with  sublimate  gauze  and  a 
moist  dressing.  Continuous  irrigation  of  cold,  tepid,  or  wai'm  sublimate 
(1  to  5,000)  may  be  added  to  the  loose  gauze  dressing,  or  not,  as  may  l)e 
determined  by  the  demands  of  any  case.  This  method  is  mainly  prophy- 
lactic. Cold  irrigation  will  be  most  generally  gratefiil.  Extreme  heat  or 
cold,  however,  should  be  used  with  caution  in  all  cases  where  the  circu- 
lation of  the  part  is  seriously  impaired  by  the  inflammatory  process. 
When  an  extremity  is  affected,  elevation  of  the  part  is  indicated.  Ten- 
sion should  always  be  relieved  by  puncture  or  incision,  even  when  sup- 
puration and  pus  inflltration  are  not  evident.  The  principle  of  drainage 
applies  here  as  in  other  wounds,  and  the  free  outlet  of  all  purulent  mat- 
ter is  essential.  Incisions,  when  x^i'^cticed,  should  be  in  the  direction  of 
the  veins  of  the  part,  so  that  these  need  not  be  divided,  and  should 
always  extend  deep  enough  to  relieve  tension  and  to  give  free  exit  to 
all  septic  matter.  The  method  of  injecting  carbolic  acid  into  the  skin 
and  subcutaneous  tissues,  at  a  distance  of  from  one  to  two  inches  from 
the  red  limit  of  the  erysipelatous  flush,  in  order  to  check  the  further 
invasion  of  the  disease,  is  of  doubtful  efficacy  and  propriety.  The  same 
should  apply  to  "firing"  with  the  actual  (cautery  or  lunar  caustic  for  the 
same  purpose. 

The  constitutional  measures  look  to  the  support  of  the  patient,  and  to 
the  antagonism  of  the  specific  poison.  Since  constipation  and  gastric 
disturbance  are  the  rule,  a  saline  laxative  should  be  given,  but  not  to  the 
extent  of  producing  exhaustive  diarrhoea.  Purgation  is  not  indicated  in 
enfeebled  and  emaciated  subjects.  For  the  rapid  pulse,  tincture  of  aco- 
nite-root may  be  employed,  and  antipyrine,  10  to  20  grains  every  two  or 
three  hours  until  the  temperature  falls  to  al)out  the  normal.  Tincture 
of  the  chloride  of  iron,  8  to  15  drops  three  or  four  times  a  day,  has  long 
enjoyed  a  high  reputation  in  the  treatment  of  this  disease,  and  the  same 
is  true  of  quinia  in  full  doses. 

Tetanus. — Traumatic  or  surgical  tetanus  differs  from  the  idiopathic 
variety  of  this  affection  only  in  the  presence  of  a  wound,  which  is  the 
starting-point  of  the  irritation  which  ends  in  imjelifis.  Any  lesion,  how- 
ever small  or  seemingly  insignificant,  and  upon  any  portion  of  the  body, 
may  serve  as  the  starting-point  of  this  affection.  Wounds,  however,  of 
the  plantar  and  palmar  surfaces,  and  in  the  distribution  of  the  trifacial 
nerves,  are  believed  to  be  especially  liable  to  induce  a  central  myelitis. 
Irritation,  however,  without  a  solution  of  continuity,  may  i^roduce  this 


WOUNDS. 


85 


ten'ible  disease,  and  it  has  been  observed  that  the  epidemic  form  of 
tetanus  is  more  likely  to  occur  when,  added  to  an  injury,  the  atmospheric 
conditions  are  unfavorable.  It  is  more  fj-equently  met  with  in  hot  than 
in  temperate  climates. 

Thus,  as  cited  by  Gross  and  Hamilton,  among  the  wounded  of  Aber- 
crombie's  command,  who,  after  the  defeat  at  Fort  Ticonderoga,  in  the 
summer  of  1758,  were  exposed  to  inclement  weather,  in  open  boats  upon 
Lake  George,  during  tlie  entire  night  following  the  engagement,  an  epi- 
demic of  tetanus  prevailed,  in  which  nine  cases  died.  Sudden  and  pro- 
longed exposure  to  cold  or  in  a  damp  atmosphere  after  a  wound  always 
adds  to  the  danger  of  being  attacked  by  this  disease.  The  impression 
prevails  among  the  inhabitants  of  Long  Island,  especially  along  the  east 
shore,  that  they  are  especially  susceptible  to  lock-jaw  ;  and  that  this  is 
more  than  conjecture  I  am  convinced,  for  I  know  personally  of  several 
cases  occurring  in  this  vicinity. 

The  time  which  may  elapse  between  the  receipt  of  the  injury  and  the 
appearance  of  the  muscular  spasms  varies  from  a  few  hours  to  several 


weeks  ;  usually  within  the  first  three  weeks  after  the  injury.  The  earlier 
symptoms  refer  to  an  unusual  degree  of  irritation  and  pain  in  the  wound, 
which  is  apt  to  be  out  of  proportion  to  the  degree  of  inflammation  present. 
The  sense  of  pain  is  often  referred  along  the  sensory  tracts  toward  the 
centers.  Irritability,  a  sense  of  unusual  muscular  excitability,  a  feeling 
of  malaise  and  apprehension,  are  among  the  symptoms  which  precede  the 
convulsive  attacks.  The  muscles  supplied  by  the  motor  filaments  of  the 
fifth  nerve  are  among  the  earliest  to  respond  to  this  abnomial  stimulus, 
hence  the  commonly  accepted  term  of  lock-Jaw.  In  the  milder  cases  the 
tonic  spasms  may  be  altogether  confined  to  these  muscles.  In  severer 
cases  the  sense  of  distress  is  referred  to  the  ei)igastric  region,  and  this  is 
followed  by  tonic  muscular  contraction,  ccmimencing  with  the  diaphragm, 
and  involving  in  quick  succession  the  muscles  of  the  jaws,  larynx,  and 
back  of  the  neck  and  dorso-lumbar  region.  Respiration  is  interrupted, 
the  expression  of  distress  is  extreme,  the  face  becomes  cyanotic,  and 
death  may  occur  from  fixation  of  the  respiratory  muscles.  The  chief 
distortion  is  that  of  more  or  less  complete  extension  of  the  spine  {opis- 


86  A  TEXT-BOOK   ON   SURGERY. 

thotonos).  An  exaggerated  illnstration  of  this  condition  is  given  in  Fig. 
148,  from  the  well-known  i)icture  of  Sir  Charles  Bell.  When  the  tonic 
spasms  are  confined  to  the  anterior  iimsries,  and  the  l)ody  is  bent  foi-ward, 
the  condition  is  known  as  empioslhofonos,  and  if  curved  laterally,  pleu- 
rothotonos.  The  spasm  continues  uutil  the  muscles  are  unable  longer 
to  contract,  when  a  gradual  and  partial  relaxation  occurs.  Successive 
attacks  f(jllow  rapidly,  being  precipitated  by  the  slightest  cause,  as  the 
jar  communicated  by  walking  upon  the  floor,  or  the  contact  of  the  hair 
or  clothing  upon  the  hypera^sthetic  integument. 

Notwithstanding  the  violent  nature  of  this  affection,  the  mind,  in  the 
great  majority  of  cases,  i-emains  clear  until  carbonic-acid  poisoning  occurs 
from  prolonged  fixation  of  the  respiratory  muscles.  The  pulse  and  tem- 
perature vary  between  great  extremes,  records  of  the  former  running 
from  the  normal  up  to  160  beats  per  minute,  and  of  the  latter  from  98"5° 
to  112°  F.  The  intense  heat  which  is  premonitory  of  a  fatal  termination, 
and  which  continues  for  a  considerable  while  after  death,  is  supposed  to 
be  due  to  coagulation  of  the  albuminoid  principle  of  muscle,  the  myosin 
(Fricke).  Death  may  take  place  in  a  single  paroxysm,  or  the  patient 
may  survive  a  number  of  attacks. 

Prognosis. — The  danger  of  death  diminishes  if  the  i^atient  survives 
the  fifth  day,  although  the  vast  majority  of  cases  end  fatally  before  this. 
The  gravity  of  the  i)rognosis  usually  depends  upon  the  violence  of  the 
paroxysms,  the  rise  in  pulse  and  temperature  being  also  propcjrtional  to 
the  severity  of  the  convulsions.  The  period  which  elapses  between  the 
receipt  of  the  accident  and  the  appearance  of  the  tetanic  spasms  is  not 
without  importance  in  jirognosis,  the  chances  of  recovery  being  increased 
with  the  longer  interval.  The  death-rate  in  those  cases  in  which  tonic 
spasms  occurred  within  two  weeks  after  the  injury  is  62  per  cent ;  from 
14  to  21  days,  17  per  cent ;  21  to  44  days,  17  per  cent ;  50  per  cent  of  all 
fatal  cases  terminate  within  5  days  after  the  first  paroxysm  ;  33  per  cent 
ivom  the  fifth  to  the  tenth  day. 

l>iagnosls. — Hysteria  is  niore  apt  to  be  mistaken  for  tetanus  than 
any  other  disease.  In  hysteria  there  is  usually  no  elevation  of  tempera- 
ture, and  the  s\^nptoms  of  great  and  acute  distress  are  wanting.  Hys- 
teria occurs  chiefly  in  females ;  tetanus,  in  a  large  majority  of  cases,  in 
the  opposite  sex. 

It  may  be  necessary  at  times  to  differentiate  between  the  tetanoid 
spasms  of  strychnia-poisoning  and  true  tetanus. 

Strychnia  tetanus  ensues  within  a  few  minutes  after  the  poison  has 
been  taken ;  the  muscles  of  the  jaw  are  not  first  affected  as  in  tetanus, 
and  are  not  always  rigid  during  the  attack.  The  convulsive  movements 
in  strychnia-poison  are  of  short  duration,  and  complete  relaxaticm  occurs, 
while  in  tetanus  the  muscular  rigidity  is  continuous. 

Hydrophobia  may  be  distinguished  from  tetanus  in  the  character  of 
the  lesion  which  causes  it,  the  peculiar  clonic  or  interrupted  spasm  of 
the  muscles,  especially  those  of  the  larynx,  and  in  the  generally  longer 
period  of  incubation  in  rabies. 

Pathology. — The  lesion  of  tetanus  is  believed  to  be  a  myelitis.     Th3 


GUNSHOT   WOUNDS.  87 

gray  matter  of  the  cord  and  medulla  is  found  deeply  injected,  or  it  may 
have  undergone  granular  degeneration.  In  some  instances  no  appreciable 
interference  with  the  nutrition  of  the  gray  matter  can  be  discovered. 

Treatiiwnt. — The  Iccal  measures  should  be  employed  to  reduce  the 
irritation  in  the  wound.  Relief  of  all  tension  should  be  secured  by  inci- 
sions, if  necessary,  and  free  discharge  should  be  maintained,  if  there  is 
septic  matter  in  the  tissues. 

Amputation  when  the  wound  is  situated  upon  one  of  the  extremities, 
stretching  or  division  of  the  sensory  nerve  leading  to  the  spine,  excision 
of  the  wound,  and  other  surgical  measures,  have  been  tried,  but  without 
a  success  which  would  warrant  a  repetition  of  these  measures. 

The  most  perfect  quiet  is  to  be  maintained,  and  the  administration  of 
concentrated  nourishment  must  be  insisted  upon  in  the  intervals  of  the 
attacks  ;  and  rectal  alimentation  should  be  practiced  if  there  is  inability 
to  swallow. 

Chloral  hydrate  in  large  doses  has  been  successful  in  some  cases. 
From  thirty  to  forty  grains  have  l^een  given  and  rejDeated  at  intervals  of 
one  hour  and  a  half.*  The  inhalation  of  chloroform  is  also  highly  recom- 
mended. The  extract  of  cannabis  Indica  (Squires)  in  doses  of  gr.  ss. 
every  two  hours,  together  with  tlie  application  of  ice  to  the  spine,  is  a 
jilan  of  treatment  highly  recommended. 

GinisJiot  Wounds. — Wounds  of  this  variety  may  properly  be  divided 
into  thos^e  in  ciril  and  those  in  miUtary  practice.  In  civil  life  the 
wounds  inflicted  by  the  shot-gun,  small-bore  himting-rifle,  pocket-pis- 
tol, and  toy  guns,  are  much  less  dangerous  than  those  made  by  the 
more  formidable  weapons  emploj^ed  in  warfare. 

"With  the  exception  of  the  charge  projected  by  the  shot-gun  and  the 
small  hunting-riiie,  all  missiles  now  used  are  conoidal  or  oblong  in  shape 
(Fig.  149). 

Projectiles  fired  from  ordnance  are  both  round  and  conoidal,  solid 
and  hollow,  the  latter  being  usually  explosive.  Grape,  canister,  l)ombs, 
and  some  solid  shot;  are  spherical,  while  most  of  the  shells  are  cylindro- 
conoidal. 

A  gunshot  wound  is  always  contused  or  lacerated.  It  may  be  simjile 
or  compJicuted :  simple  when  the  missile  alone  passes  through  the  tissues  ; 
complicated  when  fragments  of  cartridge,  wadding,  jDOwder,  clothing,  or 
other  foreign  matters  are  carried  in  with  it. 

The  degree  of  laceration  made  by  a  gun-projectile  is,  as  a  rule,  in  an 
inverse  ratio  to  the  rapidity  of  its  projection.  It  may  also  depend  upon 
the  shape  of  the  missile,  and  the  additional  destruction  caused  by  dis- 
]ilaced  fragments  of  bone,  etc.  A  conoidal  projectile  is  more  destructive 
than  one  wliich  is  spherical,  for  when  in  its  transit  the  point  meets  with 
resistance,  it  tends  to  turn  over  and  over  on  its  long  axis,  loses  in  great 
part  its  axial  rotnticm,  and  thus  plunges  through  the  tissues.  When  a 
l)all  passes  in  and  out  of  the  body,  it  will  be  found  that  the  wound 
of  entrance  is  smaller  than  tluit  (jf  exit,  and  is  seemingly  much  smaller 

*  Hammond,  '•  Diseases  of  the  Nervous  System."    D.  Appleton  &  Co. 


88 


A  TEXT-BOOK   ON   SITIGERY. 


than  the  projectile.  Tlie  infolding  of  tlie  skin  anrl  its  elasticity  will 
account  for  the  small  size  of  the  entrance.  The  diiniimtion  of  the 
momentum,  and  the  tumbling  of  the  projectile  as  it  jjluiiges  through 
the  tissues,  together  with  the  non-resistance  of  the  skin  at  the  exit,  will 

account  for  the  larger  size  of  this 
opening.  When  a  ]>i-ojectile  pass- 
es completely  tlirougii  the  tissues 
there  is  usually  a  single  opening 
of  exit.  Occasionally  the  object 
is  divided  after  entrance,  and 
makes  two  or  more  holes  of  exit, 
or  one  part  of  the  bullet  may 
lodge  and    the  other   pass   out. 


Fig.  149. — Table  of  weights  (in  grains)  of  the  balls  at  present  in  use  in  the  armies  of  various  nations.  With 
the  exception  of  No.  6,  the  cuts  approximate  the  actual  size  of  the  missiles.  1,  Sprini;field  rifle,  500 
grains  (.A^'new).  2,  Kntield  rifle,  530  trrains  (Agnew).  3,  Austrian  rifle  (old), -400  grains  (Agnew). 
4,  Chasscpot  rifle,  .387>f  grains  (Fischer).  5,  Needle-L'un,  5.30  grains  (Agncw).  6,  Mitrailleu>c,  840 
grains  (A,'new).  7,  Bavarian  rifle,  386  grains  (I'I^cIrt).  8,  Snider  rifle,  about  400  irrains.  9,  Musket- 
ball,  4S0  grains  C\gnew).  10,  Belgian  rifle,  385  grains  (Fischer).  11,  Martini-Henry  rifle,  4S5  grains 
(Fischer)i  li,  Italian  rifle,  310  grains  (Fiseheri.  13,  Netherland  rifle, . 3.37  grains  (Fischer).  14,  Austrian 
rifle  (nen),  872  grains  (Fischer).   15,  Russian  rifle,  372  grains  (Fischer).  IG,  Swiss  rifle,  310  grains  tFischer). 

Fragments  of  bone  or  teeth  displaced  by  a  missile  may  be  driven  out 
through  the  integument. 

If  the  velocity  of  a  missile  is  great,  and  the  tissues  traversed  offer  no 
special  resistance,  the  wound  of  exit  will  be  in  the  direct  line  of  that  of 
entrance.  Bodies  traveling  with  diminished  velocity  or  meeting  with 
formidable  resistance  will  be  deflected,  and  may  piirsue  a  most  unex- 
pected course.  Instances  are  recorded  of  l)ullets  which  have  made  a  half 
or  the  entire  circuit  of  the  body,  passing  just  beneath  the  skin.  Still 
more  remarkable  are  the  instances  of  extensive  fracture  of  bones  which 
have  been  produced  without  any  evidence  of  injury  to  the  integument. 
Longmore  *  relates  the  case  of  a  soldier  who  had  the  whole  shaft  of  the 


♦  Holiiies'9  "  Surgery,"  vol.  ii,  p.  134.    William  Wood  &  Co.,  1875. 


GUNSHOT   WOUXDS.  89 

humerus  shattered  by  a  cannon-ball,  yet  the  skin  remained  as  white  and 
as  sound  as  if  it  had  not  been  touched.  Numerous  instances  of  similar 
lesions  are  recorded. 

Treatment. — As  with  all  other  wounds,  the  arrest  of  hsemori'hage  is 
the  iirst  indication  in  gunshot  injuries.  The  various  means  to  accom- 
plish this  end  have  already  been  given.  It  should  be  the  recognized 
duty  of  the  profession  to  instruct  the  general  public  in  the  use  of  the 
simpler  means  for  arresting  hsemorrhage.  In  military  service  each  soldier 
should  be  taught  by  actual  demonstration  where  and  how  to  make  com- 
pression in  order  to  control  the  blood-supply  to  a  part.  In  actual  warfare 
the  vessels  should  be  outlined  by  nitrate-of -silver  tracings,  and  with  especial 
indications  at  those  points  where  pressure  will  prove  most  efficient.  The 
ready  construction  of  a  tourniquet  l)y  means  of  a  belt,  coat-sleeve,  bridle- 
rein,  etc.,  tied  around  the  Umb  at  the  proper  place,  and  then  twisted  by 
a  bayonet,  sword,  gun-barrel,  or  stick,  is  an  important  lesson  for  an 
emergency.  Xext  in  order,  and  no  less  essential  in  the  successful  man- 
agement of  a  gunshot  wound,  is  cleanliness  and  dralnarje.  In  the  best- 
regulated  armies  of  to-day  each  soldier  carries  in  his  cartridge-box  a  well- 
protected  ball  of  iodofomiized  gauze,  with  the  instructions  to  lay  this  over 
the  wound  as  sixui  as  possible,  and  to  hold  it  there  by  a  belt  or  bandage 
until  the  surgeon  arrives.  In  the  antiseptic  treatment  of  these  injuries 
irrigation  with  1  to  3,000  sublimate  solution  is  thoroughly  done.  All 
foreign  matter  or  fragments  of  bone  or  destroyed  tissues  are  removed, 
bone,  catgut,  or  rubber  drains  inserted,  and  the  regulation  antiseptic 
dressing  applied. 

When  sublimate  solution  can  not  be  had,  1  to  20  to  30  carbolic  acid 
is  next  in  order  of  jsreference  ;  and,  if  neither  of  these  articles  is  avaU- 
able,  the  freshest  and  purest  water  should  be  employed. 

Following  a  serious  gunshot  or  other  injury  (or  at  times  a  violent 
emotion  without  any  appreciable  lesion),  a  condition  of  prostration  or 
partial  collapse  occurs,  which  is  known  as  shock.  8hock  may  be  defined 
as  a  condition  of  collapse  resulting  from  jjhysical  injury  or  mental  emo- 
tion (one  or  both)  whereby  the  functions  of  the  nerve-centers  are  more  or 
less  completely  suspended.  The  degi-ee  of  shock  is  often  determined  by 
individual  susceptibility,  and  is  not  always  in  proportion  to  the  severity 
of  the  injury.  The  symptoms  are  pallor,  coldness  of  the  skin,  thready, 
irregular,  or  rapid  pulse,  nausea,  vomiting,  clammy  perspiration,  and  an 
anxious  and  fixed  expression. 

Judicious  stimulation  is  the  great  indication,  for,  while  reaction  must 
b3  brought  about,  the  quantity  of  stimulants  should  be  kept  at  the  pos- 
sible minimum,  for  an  excess  will  only  add  to  the  fever  of  reaction.  Rye 
whisky  by  the  mouth,  rectum,  or  hypodermically,  should  be  preferred. 

Hot  bottles,  warmed  blankets,  friction,  etc.,  are  Txseful  adjuvants  in 
the  treatment  of  shock. 

The  advisability  of  searching  for  a  gunshot  missile  which  has  lodged 
in  the  body,  or  which  has  traversed  any  of  the  cavities,  as  well  as  the 
treatment  of  wounds  of  special  organs,  will  be  discussed  hereafter. 


CHAPTER  VII. 

BUKNS  AND  SCALDS. — FROST-BITE. 

Burns  and  scalds  are  classified  in  degrees  varying  from  the  mildest 
form,  which  produces  a  simple  inflammation  of  the  epidermis,  to  the  most 
severe  form,  which  destroys  all  the  tissues  or  organs  of  a  i)art.  The 
gravity  of  the  prognosis  is  usually  in  proi^ortion  to  the  extent  of  surface 
of  the  integument  destroyed  rather  than  to  the  depth  of  the  destructive 
process.  Burns  of  the  head  and  face  are  most  dangei-ous ;  those  of  the 
extremities  least  grave.  Recovery  is  exceptional  after  destructi(m  of  one 
third  of  the  cutaneous  surface.  Death  may  result  from  shock,  ulcer  of 
the  duodenum,  or  exhaustion  from  prolonged  suppuration  and  septic 
absorption. 

The  history  of  a  slight  burn  or  scald  involving  only  a  limited  area  of 
the  integument,  and  not  extending  beyond  the  skin,  is  simjily  one  of 
local  disturbance.  Cold-water  immersion  is  the  indication  in  treatment. 
When,  however,  a  considerable  extent  of  tissue  is  involved,  symptoms  of 
profound  constitutional  disturbance  rapidly  supervene.  The  x>atient  is 
seized  with  chills  or  rigors,  suffers  excruciating  pain,  betrays  in  his 
expression  the  extreme  anxiety  felt  as  to  his  condition,  and  sinks  into  a 
condititm  of  collapse,  wliich  is  often  the  prelude  to  a  fatal  issue.  When 
not  rapidly  fatal,  the  duration  of  this  stage  is  fi-om  six  to  thirty-six 
hours.  It  is  followed  by  the  stage  of  reaction  and  inflammation.  The 
character  of  the  febrile  movement  depends  uj^on  the  extent  of  the  destruc- 
tion of  the  tissues,  and  upon  the  concurrence  of  certain  lesions  of  the 
thoracic  and  abdominal  viscera.  Inflammation  of  the  duodenal  glands, 
and  the  formation  of  ulcer  with  perforation,  is  not  of  infrequent  occur- 
rence during  the  second  week  after  the  accident.  Peritonitis,  pleuritis, 
or  pneumonitis  may  add  to  the  gravity  of  the  prognosis.  Laryngitis 
and  bronchitis  are  apt  to  follow  the  efforts  at  inspiration  in  the  presence 
of  scalding  steam. 

Treatment.— The  immediate  indication  is  to  relieve  pain  by  the  admin- 
istration of  morphia  hypodermically,  or  some  form  of  opium  by  the  rec- 
tum or  stomach.  Stimulation  with  whisky  or  brandy  by  enema,  or  by  the 
mouth,  is  also  indicated  to  prevent  collapse,  or  to  modify  the  intensity  of 
shock  which  is  apt  to  follow  a  scald  or  burn.  The  use  of  both  opium  and 
alcohol  should  be  made  with  a  certain  degree  of  caution,  for  there  is 
danger  from  a  too  j)rofound  narcosis  \vith  the  former,  while  alcohol  in 


BUKNS  AND  SCALDS.  91 

excess  will  unnecessarily  add  to  the  fever  of  reaction,  which  always  fol- 
lows if  the  patient  should  rally  from  the  shock. 

The  clothing  should  l)e  carefnlly  removed,  and  the  burned  surface 
shielded  from  the  atmosphere  by  an  immediate  application  of  a  mixture 
containing  equal  parts  of  Unseed-oil  and  lime-water.  If  this  preparation 
can  not  l)e  obtained,  a  coating  of  ordinary  Avhite-lead,  as  mixed  for  use  in 
painting  dwellings,  is  an  efficient  protective  when  poured  over  the  burn. 
Flour  sprinkled  over  until  all  the  excoriated  surface  is  well  hidden  is  a 
method  of  treatment  which  may  be  carried  out  in  almost  any  emergency. 
Rubber-tissue  protective  laid  over  the  raw  surface,  and  cotton  batting 
applied  on  top  of  this,  is  equally  efficient.  Lint  dipjied  in  2-per-cent  car- 
liolized  oil  may  be  used  directly  on  the  wound.  Any  great  degree  of 
X)ressure  should  not  be  permitted  upon  the  excoriated  surfaces.  In  the 
not  infrequent  form  of  bum  in  which  the  back  and  posterior  aspects  of 
the  extremities  are  chiefly  involved,  the  prone  position  should  be  main- 
tained, i 

"When  suppuration  and  sloughing  commence,  great  cleanliness  should 
be  observed,  to  prevent  the  absorption  of  septic  matter.  The  dressings 
should  be  changed  as  often  as  the  thermometer  indicates  septicaemia,  but 
not  oftener.  Absorbent  cotton  pellets  moistened  in  1  to  3,000  sublimate 
should  be  used  in  cleansing  the  burned  surface.  A  mixture  of  vaseline 
(the  white  variety  is  preferable)  and  iodoform,  in  the  proportion  of  ?  j  of 
the  former  to  3  j  of  the  latter,  is  a  useful  dressing  in  the  stage  of  granula- 
tion. This  should  be  applied  on  surgeon's  lint,  and  covered  over  with 
rul)))er  protective.  It  often  becomes  necessary  to  arrest  exuberant  granu- 
lations by  the  free  use  of  lunar  caustic,  or  the  projecting  buds  may  be 
clipped  off  with  the  scissors — a  method  objectionable,  however,  in  the 
bleeding  which  always  follows  this  practice.  Compression  by  strips  of 
adhesive  (diachylon)  plaster  is  a  better  method  of  repressing  the  over- 
grown granulation-tissue.  When  the  destruction  of  integument  has  been 
so  extensive  that  cicatrization  can  not  be  effected  on  account  of  the  ten- 
sion of  the  part  involved,  the  transplantation  of  skin  should  be  practiced. 
The  various  methods  are  gra/Nng,  sliding,  or  transplantation  in  mass. 

Grafting  may  be  done  by  clippings  about  one  twentieth  of  an  inch  in 
diameter,  and  cut  out  so  that  only  the  epidermis  and  Malpighian  layers 
are  included.  The  epidermis  is  pinched  up  with  a  jiair  of  mouse-toothed 
forceps,  and  clipped  off  close  to  the  forceps  with  sharp  curved  scissors. 
A  spot  of  the  granulating  surface  free  from  pus  is  selected,  and  the  graft 
laid  on  bottcmi-side  down  and  pressed  snugly  into  the  granulating  bed. 
A  similar  graft  for  every  quarter-inch  of  surface  will  suffice.  These 
should  be  left  uncovered  from  one  half  to  one  hour.  A  layer  of  pro- 
tective is  then  laid  over  the  entire  surface,  and  a  light  sublinuite-gauze 
dressing  applied,  held  on  with  a  roller  or  adhesive  strips.  This  dressing 
should  remain  unmolested  for  at  least  forty-eight  hours,  in  order  to  give 
the  grafts  time  to  take  hold,  and,  when  the  dressing  is  changed,  great  care 
should  be  taken  to  pi-event  their  dislodgment.  Water  should  not  be 
used  in  the  dressing.  At  the  end  of  about  the  third  day,  if  the  graft  has 
"taken,''  a  bluish  white  spot  will  be  seen,  the  color  fading  away  gradu- 


92 


A  TEXT-UOOK   ON  SURGERY. 


ally  at  the  edges  until  it  is  merged  in  the  general  granulating  mass. 
Grafts  situated  near  the  skin  will  unite  and  proliferate  more  rai)idly  and 

surely  than   tluiso   farther   out   in   the 

-  -     -^  wound. 

y^^^it^SlJ^^  ^*''-  •^-  ^^-  tJirdner*  has  demonstrated 

f      'flSl^g-^tf  rT^m  that  i)ieces  of  skin  taken  from  a  healthy 

man  six  hours  after  death  by  accident 
"cut  into  a  great  many  small  pieces," 
and  laid  upon  a  healthy  granulating 
surface,  will  become  revitalized.  The 
results  of  this  demonstration  are  very 
valuable  (Fig.  l.W). 

Transplantations  of  skin  in  large 
pieces  by  entire  removal,  or  with  a  ped- 
icle left  until  the  vascular  suj^ply  is 
establishecj  between  the  granulating  sur- 
face and  the  transplanted  integument, 
may  also  be  successfully  acc()m])lished. 
It  is  essential  that  the  skin  which  is 
completely  detached  should  be  clii>ped 
or  scraped  on  its  under  surface  until 
only  the  Mal])ighian  layer  and  epider- 
mis are  left.  The  presence  of  fat  on  the 
reticulated  corium  will  prevent  success. 
When  sliding  is  attempted,  it  is  essen- 
tial that  the  pedicle  should  be  of  good 
width,  and  that  the  tension  on  it  should 
not  be  great,  so  that  the  integrity  of  the  blood-supply  may  not  be  inter- 
fered with,  and  sloughing  ensue.  Ui^on  the  face  and  neck,  where  the 
vascularity  is  so  great,  a  smaller  pedicle  may  be  used,  and  gi'eater  tension 
employed  than  on  other  portions  of  the  body. 

AVhen  there  is  not  sufficient  integument  immediately  about  a  Inirn  to 
supply  the  want,  the  flap  may  be  secured  from  some  other  portion  of  the 
body.  Thus  in  a  case  of  extensive  desti'uction  of  the  integument  on  the 
front  of  the  leg,  I  have  succeeded  in  covering  in  the  surface  by  turning  a 
flap  from  the  posterior  aspect  of  the  opposite  leg,  leaving  a  wide  pedicle, 
and  fastening  the  two  members  in  an  immovable  position,  so  that  the 
flap  remained  in  its  proper  place  and  free  from  strain.  After  about  ten 
days  the  pedicle  may  be  divided.  In  the  case  of  a  boy  who  had  been 
severely  burned  in  the  hand  and  forearm,  and  where  the  cicatricial  con- 
tractions displaced  the  fingers,  deformed  the  hand,  and  threatened  am- 
putation of  the  member  by  obstruction  of  the  radial  and  ulnar,  I  did 
the  following  operation  with  success  :  All  the  cicatricial  tissue  about  the 
wrist  and  arm  was  dissected  off  down  to  the  tendons  and  bones,  which 
were  in  good  condition.  Two  parallel  incisions,  six  or  seven  inches  long 
and  four  inches  apart,  were  then  made  from  the  ensiform  cartilage  down 


Fio.  150. 


*  "Medical  Record,"  vol.  sx,  p.  119. 


BURNS   AND   SCALDS. 


93 


to  the  umbilicus,  and  the  strip  of  skin  dissected  up  in  the  middle  and 
left  attached  at  both  ends.  When  the  small  amount  of  bleeding  had 
been  arrested,  the  hand  was 
slid  beneath  this  tlap,  the 
under  surface  of  which  was 
brought  in  contact  with  the 
raw  surface,  where  the  cica- 
tricial tissue  was  removed 
from  the  arm  and  held  in 


Fio.  152. — The  author's  case  of  transplantation  from  the 
men  to  the  arm. 


abdo 


Fio.  151. 

l^lace  by  stitching  the  edges 
together  with  silk.  Iodo- 
form -  sublimate  dressing 
was  applied,  and  the  hand 
and  ami  held  immovable 
by  adhesive  plaster.  Fig. 
151  shows  the  condition  of 
the  hand,  and  Fig.  152  the 

method  of  transplantation.  On  the  tenth  day  the  strip  of  skin  was 
divided  above  and  below,  and  the  ribbon  folded  around  the  wrist  and 
stitched  in  position.  The  operation  succeeded,  and  amputation  was 
avoided.  A  second  similar  operation  was  done  to  restore  the  integrity 
of  the  palm.  In  all  cases  of  transplanting  skin  no  more  of  the  sub- 
cutaneous tissue  should  be  lifted  with  the  integument  than  is  necessary 
for  the  vitality  of  the  flap.  In  short  ilaps  a  very  thin  dissection  should 
be  effected ;  in  longer  pedicles  a  good  deal  of  tissue  shoiild  be  left  to 
insure  the  safety  of  the  lilood-vessels. 

Transplanting  in  mass,  in  which  the  piece  of  integument,  at  least  one 
inch  in  surface-measurement,  is  entirely  severed  from  its  original  attach- 
ment, and  laid  uj^on  the  granulating  surface,  is  not  so  successfxd  as  the 
preceding  methods.  The  smaller  grafts  are  much  preferable.  "When  this 
operation  is  done,  the  piece  to  be  transferred  should  be  ti'immed  or 
scraped  so  thin  that  nothing  but  the  epidermis  and  Malpighian  layer 
remains.  Destruction  of  tissue  by  acids  or  alkalies  requu-es  no  especial 
consideration  beyond  the  adoption  of  measures  to  neutralize  the  excess 
of  the  agent  in  the  part  involved.     The  after-treatment  does  not  differ 


94  A  TEXT-BOOK  ON  SURGERY. 

from  that  of  the  granulating  surfaces  of  bums  and  scalds  from  fire,  boil- 
ing water,  or  steam. 

Frust-Bite. — The  effect  of  prolonged  and  extreme  cold  upon  the  aiumal 
tissues  is  to  cause  occlusion  of  the  capillaries,  loss  of  sensation,  and  death 
by  gangrene. 

The  treatment  is  to  attempt  a  gradual  restoration  of  the  circulation 
by  friction  in  a  low  temperature.  A  part  of  the  body  benumbed  by  cold 
should  never  be  submitted  suddenly  to  a  high  temperature,  but  should 
be  bathed  and  rubbed  in  snow  or  cold  water,  the  temperature  of  which 
is  slowly  elevated.  When  gangrene  results,  amputation  is  demanded 
after  the  line  of  demarkation  is  established. 

Furuncle. — A  boil  is  a  circumscribed  inflammation,  commencing 
usually  in  the  hair  follicles  and  sebaceous  glands,  and  extending  to  the 
snbcutaneous  tissues,  in  which  it  may  at  times  originate.  The  chief 
cause  is  either  a  traiimatic  or  idiopathic  inflammation  in  the  glandular 
apparatus  of  the  skin,  and  the  arrest  of  the  nutrition  of  the  jjart  by 
obstruction  of  the  capillaries  by  pressure  from  without  or  by  embolism 
or  thrombosis  from  within.  The  inflammation  spreads  to  the  STirround- 
ing  tissues,  and  localized  gangrene  ensues.  Bods  occur  very  frequently 
during  the  history  of  certain  diseases,  as  diabetes  mellitus,  tuberculosis, 
scrofula,  derangements  of  nutrition,  etc. 

The  diagnosis  is  not  difficult,  being  chiefly  between  carbuncle  and  the 
localized  necrosis  in  certain  forms  of  sypliilitic  gumma  of  the  skin. 
From  carbuncle  it  may  be  differentiated  by  the  more  acute  inflammatory 
process  of  the  furuncle,  the  single  point  of  suppuration,  the  well-defined 
limit  of  the  redness,  and  the  acute  character  of  the  pain.  In  carbuncle 
the  inflammation  extends  more  widely  and  deeper,  the  induration  is 
greater,  there  are  several  poiats  of  suppuration,  and  the  febrile  symptoms 
more  appreciable.  The  syphilitic  lesions  will  be  recognized  from  the 
history  of  the  disease.  The  treatment  lf)oks  to  an  early  relief  from 
tension  in  the  integument,  and  the  separation  and  discharge  of  the  slough 
and  pus.  Incision  should  be  performed  at  once.  The  judicious  use  of 
cocaine  hypodermically  will  prevent  pain,  and  much  suffering  will  be 
avoided  by  prompt  action.  The  application  of  cold  or  heat  is  at  times 
useful.  Poultices  are  almost  universally  employed  to  soften  the  skin  and 
hasten  the  discharge  of  the  dead  tissue.  It  is  a  waste  of  time  to  wait  for 
so  slow  a  process.  After  incision  a  warm,  moist  sublimate  flaxseed  poul- 
tice or  dressing  should  be  applied,  and  continued  until  a  cure  is  effected. 

The  constitutional  treatment  should  be  directed  to  the  correction  of 
any  existing  dyscrasia.  The  preparations  of  iron  and  mercury  are,  in 
my  opinion,  the  best  general  remedies.  Tonics,  good  food,  regulation  of 
the  alimentary  apparatus,  and  good  hygiene,  are  essential.  Sulphide  of 
calcium,  gr.  ^  to  \,  three  or  four  times  a  day  ;  arsenic,  the  iodides,  cod- 
liver  oil,  with  the  hypophosphites  of  lime  and  soda,  are  among  the 
remedies  most  recommended. 

Carbuncle. — This  disease— which,  as  Prof.  A.  R.  Robinson*  Justly 

*  "  Manual  of  Dermatology,"  1884. 


CARBUNCLE.  95 

remarks,  has  been  misnamed  '•'•anthrax'''' — is  characterized  by  an  inflam- 
matorj^  process  of  a  low  order,  involving  chieiiy  the  skin  and  the  con- 
nective tissues  immediately  beneath  it,  and  in  some  instances  extending 
into  the  deeper  organs.  Carbuncle  is  a  disease  of  malnutrition.  The 
process  is  akin  to  that  of  furuncle,  though  indicative  of  a  more  depraved 
condition  of  the  tissues.  The  cause  is  capillary  thrombosis  or  embolism, 
and  subsequent  inflammation  spreading  from  the  necrotic  focus.  Gan 
grene  always  occurs,  and  the  inflamed  area  breaks  douTi  in  several  places, 
giving  discharge  to  pus  usually  in  small  quantity,  as  well  as  to  dead  tissue. 

It  is  apt  to  occur  as  a  complication  of  the  same  diseases  with  which 
furuncles  are  seen  —  namely,  diabetes  mellitus,  tuberculosis,  scrofula, 
etc.  It  is  apt  to  occur  in  parts  of  the  economy  subjected  to  more  than 
ordinary  ii'ritation,  as  the  back  of  the  neck,  where  the  collar  presses, 
and  in  the  gluteal  region. 

The  symptoms  of  this  affection  are  a  sense  of  malaise,  loss  of  appetite, 
headache,  fevei',  varying  in  intensity,  which  is  followed  by  or  accom- 
panied with  a  deep-seated  and  severe  pain  in  and  about  the  local  expres- 
sion of  the  disease.  The  sldn  at  this  point  becomes  tense,  injected, 
doughy  to  the  touch,  throbbing  and  painful ;  the  epidermis  becomes 
lifted  at  various  spots  in  the  inflamed  area,  vesicles  form,  localized  gan- 
grene occurs,  and  the  dead  matter  sloughs  away.  Not  infi-e(iuently  the 
necrotic  j^rocess  rapidly  extends  through  the  areolar  tissue  beneath  the 
skin  some  time  before  the  integument  breaks  down.  The  extent  of 
necrosis  varies  under  different  conditions,  and  may  be  general  or  limited. 
The  constitutional  symptoms  are  deteimined  by  the  amount  of  septic 
absorption  and  the  degree  of  pain  experienced. 

The  process  of  repair  is  by  granulation,  the  development  of  an  em- 
bryonic tissue  which  advances  from  the  sides  and  bottom  of  the  cavity 
as  the  slough  is  carried  away.  As  to  the  length  of  time  carbuncle  may 
last,  nothing  positive  can  be  stat^-'d.  Usually  from  three  to  seven  weeks  ; 
at  times,  when  the  process  is  subacute,  several  months. 

The  prognosis  depends  upon  the  condition  of  the  patient,  the  age, 
the  location  and  extent  of  the  lesion,  and  the  ability  of  the  capillaries 
and  IjTuphatics  to  resist  septic  absoi-ption.  Occurring  in  diabetes  or  any 
dangerous  malady,  it  hastens  a  fatal  issue.  Situated  upon  the  face,  the 
gravity  of  the  prognosis  is  increased.  This  is  in  gi-eat  part  due  to  the 
intenst^  pain  which  follows  an  invasion  of  that  part  of  the  body  in  which 
the  trifacial  nerve  is  distributed.  When  located  on  the  thorax,  the 
pleura  may  become  involved,  thereby  causing  a  grave  complication. 

The  treatment  should  look  to  the  immediate  improvement  of  the 
patient's  vitality  by  all  available  means.  The  local  treatment  should  be 
directed  to  the  relief  of  tension,  the  arrest  of  the  invasion,  and  the  dis- 
charge of  septic  matter. 

The  only  possible  objection  to  earl}-  and  free  incision  is  h;emon-hage, 
and  the  operator  has  only  to  decide  between  the  danger  of  sepsis  from 
delayed  diainage  on  the  one  hand,  and  that  of  loss  of  blood  on  the  othei*. 
To  my  mind,  the  fear  of  hjemorrhage  is  unfounded,  and  slit>uld  not  cause 
a  delay  in  making  the  incisions.     The  patient  should  be  anjesthetized. 


96 


A  TEXT-BOOK   ON   SURGERY. 


and  the  indurated  mass  incised  well  down  to  the  bottom  in  several  direc- 
tions. Crucial  cuts,  or  several  ]):ii':i1Ip1  incisions,  or  lines  radiating  from 
the  center,  may  be  made  as  the  location  and  size  of  the  carbuncle  may 
indicate.  If  undermining  has  been  extensive,  drainatre-tubes  should  be 
employed.  Hjemorrhage  may  be  controlled  hj  packing  with  sublimate 
gauze.  The  after-treatment  should  be  hot  or  warm,  sublimate-gauze 
dressings  applied  loosely,  and  covered  in  with  protective  or  oil-silk. 
Poultices,  if  employed,  should  be  made  with  sublimate  solution,  as  here- 
tofore directed. 

Ulcerfi. — An  ulcer  is  the  result  of  molecular  death  in  the  integument 
or  mucous  membrane,  and  the  underlying  areolar  or  submucous  tissue. 
The  process  of  necrobiosis  may  at  times  extend  below  the  deep  fascia. 
Of  whatever  variety,  an  ulcer  is  caused  by  a  failure  of  nutrition  in  the 
part  affected.  The  arrest  of  nutrition  may  be  local,  as  in  the  ulcer  of 
chancroid  or  with  a  varico.se  condition  of  the  veins,  or  constitutional,  as 
in  the  late  manifestations  of  syphilis,  in  scorbutus,  etc.  Occurring  with 
a  dyscrasia,  ulcers  are  even  then  more  apt  to  occur  in  parts  of  the  body 
subjected  to  abnormal  interference  with  the  circulation. 

Specific  ulcers  will  be  considered  Avith  the  diseases  of  which  they 
form  a  part.     Ulcers  may  be  divided  into  two  clinical  groups — the  active 
and  indolenf.     In  one,  the  material  for  repair  is  in  excess  ;  in  the  other, 
it  is  deficient.     The  most  frequent  seat  of  ulcer  is  upon  the  anterior 
aspect  of  the  tibia  at  its  middle  and  lower  portions. 
i      They  occur  almost  always  in   the  aged,  and  chiefly 
\  ^^      among  the  poorly  fed  and  laboring  classes,  where  the 

\  ,  )  erect  posture  is  of  necessity  maintained  for  many  suc- 
cessive hours.  Varicosities  of  the  veins  of  the  lower 
extremities  must  be  put  down  as  the  most  common 
non-specific  cause  of  ulcers. 

The  treatment  of  ulcers  must  be  directed  to  the 
cause  of  the  tissue  destruction.  In  varicosities  the  in- 
tegi'ity  of  the  circulation  should  be  restored  by  sup- 
porting the  vessels  by  mechanical  means,  or  relieving 
the  overpressure  by  position.  For  the  former  the  elas- 
tic stocking,  properly  adjusted,  is  invaluable.  Mar- 
tin's elastic  bandage  is  an  excellent  apparatus,  but  re- 
quires considerable  care  in  its  even  and  skillful  appli- 
cation. When  neither  of  these  methods  is  available, 
pressure  may  be  successfully  employed  by  means  of 
flannel  or  muslin  bandages.  An  elevated  iiosition  of 
the  foot  and  leg  should  be  maintained  in  all  ulcers  of 
the  lower  extremities. 

An  indoJent  iilcer  demands  stimulation.  This  may 
be  effected  by  the  oakum -dressing.  Soft,  clean  oakum 
should  be  well  soaked  in  1  to  3,000  sublimate,  squeezed 
out,  laid  over  the  ulcer,  and  held  well  in  plnce  by  a 
roller.     It  should  be  changed  every  three  or  four  days. 


^■\ 


Fio.  153. 


Sublimate  gauze  is  also  an  efficient  stimulating  dress- 


GANGRENE.  97 

ing.  Either  of  these  methods  should  take  the  place  of  the  old  practice 
of  burning  such  ulcers  with  escharotics.  Supporting  the  edges  of  the 
sore  with  well-adjusted  strips  of  diachylon  plaster  is  also  a  conimendaV)le 
practice.  The  strips  should  be  cut  about  three  fourths  of  an  inch  wide, 
and  crossed  in  a  si:)iial  manner  (Fig.  153). 

Irritable  ulcers  require  rest  and  soothing  applications.  lodoform- 
vaseline  ointment  ( 3  j  to  5  j  i  will  be  found  of  value.  It  should  be  applied 
on  .soft  canton-tlannel  or  lint,  and  not  strapped  down  tightly.  The  con- 
stitutional treatment  of  all  patients  suffering  from  ulcers  is  of  lirst  im- 
portance. 

Gangrene  is  death  of  a  part  of  the  body  from  the  gradual  or  sudden 
an-est  of  its  nutrition.  It  is  usually  applied  to  the  process  of  mortifica- 
tion in  the  softer  structures.  The  analogous  condition  of  bone  is  called 
necrosis.  Animal  tissues  have  two  modes  of  dying — the  one  is  molecu- 
lar, or  death  by  granular  metamorphosis,  in  which  no  trace  of  the  ana- 
tomical or  histological  properties  of  the  tissues  remains ;  the  other  is 
death  hi  bulk,  in  which,  although  the  tissues  deprived  of  life  undergo 
rapid  decomposition  and  ultimate  disintegration,  they  retain  for  a  time 
something  of  their  original  form.  It  is  to  denote  this  last  variety  of  tis- 
sue-death that  the  term  gangrene  is  employed. 

There  are  three  varieties — namely,  the  acute,  or  moist ;  the  chronic, 
senile,  or  dry ;  and  the  contagious,  pTiagedenic,  or  hospital  gangrene. 

Acute  Gangrene. — The  chief  cause  of  moist  gangrene  is  the  sudden 
obstruction  of  the  afferent  or  efferent  vessels  of  a  part.  Whether  the 
artery  is  alone  occluded,  as  by  an  embolus,  the  ligature,  or  an  accidental 
solution  of  its  continuity  ;  or  whether  the  venous  current  is  arrested 
while  the  artery  is  permeable ;  or  whether  the  arrest  in  both  systems  is 
simultaneous,  as  by  the  constriction  of  a  finger  with  a  ring,  or  in  the  case 
of  a  strangulated  hernia — the  part  beyond  the  lesion  is  charged  with 
blood  which,  arrested  in  its  flow,  loses  its  vitality  and  takes  an  early  part 
in  the  work  of  decomposition  which  ensues. 

"When  an  artery  is  obliterated,  tlie  vitality  of  the  tissues  on  the  periph- 
eral side  of  the  occlusion  depends  upon  the  integrity  of  the  collateral  cir- 
culation. If  the  occlusion  is  gradual,  the  enlargement  of  the  collateral 
branches  is  usually  sufficient  to  carry  the  necessary  supjily  of  blood. 
There  is  scarcely  a  point  in  the  arterial  system  where  a  collateral  route 
may  not  be  established,  provided  that  the  process  of  obliteration  is  not 
too  sudden,  and  that  the  blood  has  not,  by  reason  of  constitutional  dis- 
turbance, been  deprived  of  its  nutritive  properties.  When  these  condi- 
tions do  not  prevail,  mortification  ensues  with  a  rapidity  i:)roportionate 
to  the  partial  or  total  arrest  of  nutrition.  Pallor  is  the  immediate  and 
earliest  symptom  of  arterial  obstruction,  followed  by  coldness  of  the 
skin,  and  pain,  which  is  usually  not  aciite.  Beginning  in  the  parts 
farthest  removed  from  the  heart,  the  phenomena  of  death  extend  toward 
the  center  iintil  the  border-line  is  reached  between  the  living  and  dying 
tissues.  Congestion  and  swelling  are  not  marked  features  of  arterial 
gangrene.  The  normal  contractility  of  the  tissues,  an  elevated  jiositifm, 
and  the  influence  of  the  return  cui-rent  in  veins  with  which  those  of  the 


98  A  TEXT-BOOK  ON   SURGERY. 

part  involved  communicate,  tend  to  empty  the  vessels  beyond  the  seat 
of  obstruction.  Of  necessity,  however,  a  considerable  quantity  of  blood 
remains,  and  when  its  flow  is  arrested  its  function  is  lost,  and  its  elements 
join  in  the  general  decomposition  which  ensues.  In  the  putrefactive 
process,  gases,  notably  sulphuretted  hydrogen  and  those  resulting  from 
decomposition  of  the  fatty  tissue,  are  evolved,  and  the  coloring-matter  of 
the  blood  is  liberated.  Myosin,  the  albuminous  jirinciple  of  muscle, 
coagulates,  giving  a  temporary  sense  of  rigidity,  and  the  serum  wliich 
remained  in  the  vessels  undergoes  transudation,  and  is  generally  dis- 
tributed among  the  tissues.  Cutaneous  sensibility  is  soon  lost,  and  the 
momentary  paUor  gives  way  to  a  grayish  hue,  which  deepens  into  a 
greenish-black  color.  Though  not  so  marked  as  in  the  condition  result- 
ing from  venous  occlusion,  the  skin  and  subcutaneous  tissues  become 
infiltrated  with  fluid  and  gases,  giving  a  doughy  feel  upon  pressui'e,  and 
at  times  the  peculiar  crackling  of  emphysema.  Serum  and  hydrogen,  in 
the  effort  to  escape,  may  at  various  points  be  caught  under  the  imper- 
vious epidennis,  wliich  is  lifted  up  into  blisters.  In  resisting  gangrene, 
certain  tissues  retain  their  anatomical  features  longer  than  others.  Bone 
and  tendon  are  slow  to  disappear,  and  at  times  the  arteries  will  resist 
destructive  change,  when  the  tissues  through  which  they  pass  have  been 
entirely  destroyed. 

In  a  case  which  recently  came  under  my  ol)servation,  through  the 
courtesy  of  Prof.  Fluhrer,  at  Mount  Sinai  Hospital,  in  which  gangrene 
was  induced  by  a  plaster-of-Paris  dressing  (applied  in  another  institu- 
tion for  supposed  fracture  of  the  humerus),  mortification  was  present 
lu'st  in  the  thumb  and  the  tip  of  the  index-finger,  gradually  involving 
the  other  fingers  and  the  back  of  the  hand  to  the  carpus,  where  the  pro- 
cess seemed  arrested  in  an  apparent  line  of  demarkation  in  the  integu- 
ment. The  gangrene  continued,  however,  beneath  the  skin,  involving 
the  extensor  muscles,  which,  after  amputation  above  the  ell)ow,  were 
found  to  have  entirely  disappeared,  while  much  of  the  integument  over 
them  retained  its  vitality.  When  once  inaugurated,  mortification  extends 
to  a  point  where  nutritive  changes  in  the  tissues  are  suflSciently  active  to 
resist  death.  The  imtation  of  the  dead  tissues  produces  inflammation 
and  the  formation  of  a  zone  of  embryonic  tissue  between  the  living  and 
dead  structures.  The  line  between  this  embryonic  zone  and  the  black- 
ened slough  is  called  the  line  of  demarkation. 

The  line  of  demarkation  is,  as  a  rale,  irregular  in  extent.  AATien  a 
part  has  been  constricted  imtil  death  ensues,  the  line  of  separation  may 
be  a  weU-defined  circumference ;  but  in  arterial  occlusion  this  is  a  rare 
exception. 

Following  the  phenomena  above  detailed,  rapid  putrefactive  changes 
occur ;  the  soft  parts  drop  away  in  offensive  sloughs,  leaving  the  bone 
projecting  from  the  stump  of  this  natural  amputation. 

The  symptoms  of  gangi-ene  from  venous  obstruction  differ  in  some 
essential  features  from  mortification  after  arterial  occlusion. 

Engorgement  is  more  marked,  since  the  cardiac  and  arterial  forces  are 
at  work  in  packing  the  tissues  beyond  the  obstruction  with  blood.     The 


GAXGREXE.  99 

skin  is  of  a  purplisli  hue  from  the  start,  pain  is  intense,  and  the  swelling 
great,  and,  until  coagulation  is  accomplished,  there  is  a  sense  of  throb- 
bing in  the  affected  part.  There  is  at  first  an  elevation  of  temperature, 
which,  however,  is  of  short  duration.  Blisters  are  more  numerous,  and 
l^utrefaction  occurs  more  rapidly. 

Gangrene  from  combined  arterial  and  venous  occlusion  has  its  type 
in  a  strangulated  hernia,  or  in  mortification  of  a  finger  which  has  been 
constricted  by  a  ring.  In  this  varietj^  arrest  of  the  circulation  and  co- 
agulation of  the  blood  are  more  abrupt.  The  remaining  features  of 
this  form  of  mortification  do  not  differ  materially  from  those  heretofore 
described. 

Treatment  of  Moist  Gangrene. — When  an  artery  is  obstructed,  the 
first  indication  is  to  remove  the  obstruction.  Failing  in  this,  to  ]iromote 
the  establishment  of  a  collatei'al  circulation,  and  to  maintain  the  tempera- 
nire  of  the  part  affected.  The  position  of  the  limb  should  be  such  that 
l)ressure  upon  the  structures  through  which  the  anastomotic  branches 
run  should  be  avoided.  Cotton-batting  should  be  carefully  wrapped 
about  the  part  to  the  thickness  of  several  inches,  and  oil-silk  or  rubber- 
tissue  protective  wrapped  around  this.  No  pressure  by  bandages  should 
be  employed.  The  ai^plication  of  hot  water,  du'ecth'  or  by  bottles,  is 
to  be  deprecated,  for  heat  is  now  known  to  produce  capillary  contraction. 
The  extremity  may  be  slightly  lowered,  in  order  to  invite  the  flow  of 
blood,  although  care  shoiUd  be  taken  to  prevent  obstruction  of  the  veins. 

While  these  local  measures  are  being  adopted,  certain  constitutional 
remedies  may  be  indicated.  These  relate  primarily  to  cardiac  stimida- 
tion,  opium  to  relieve  pain  and  palliate  shock,  and  to  an  early  improve- 
ment in  the  nutritive  quality  of  the  blood  ;  the  administration  of  alcohol 
and  beef -juice,  and  the  careful  combination  of  those  articles  of  food  which 
are  acceptable  to  the  patient,  and  are  known  to  be  rich  in  nitrogen.  Any 
intercuri'ent  disease  or  complication  will  indicate  a  modification  of  the 
treatment  to  suit  the  emergency.  As  death  progresses  and  the  sloughing 
begins,  all  stnictures  which  can  be  removed  easily  and  without  pain 
should  be  cut  away  with  dressing  forceps  and  scissors.  Iodoform,  freely 
sprinkled  over  the  sloughs,  will  prove  a  good  deodorizer,  or  the  dead  part 
may  be  kept  wrapped  in  sublimate  gauze,  soaked  in  1  to  500  solution, 
and  kept  moist  by  protective.  When  the  line  of  demarkation  is  formed, 
sublimate  gauze  (1  to  1,000)  may  be  laid  around  this  locality,  to  guard 
against  septic  absorjjtion. 

IL'emorrhage  is  rare  in  this  variety  of  gangrene,  yet  when  it  does  occur 
it  demands  the  ligature  or  compression. 

The  treatment  of  gangrene  where  the  vein  alone  is  obstructed,  in 
which,  as  has  been  stated,  the  condition  of  engorgement  is  extreme, 
demands  the  elevation  of  the  part  in  order  to  facilitate  the  escape  of 
blood  through  the  venous  channels.  Tlie  tension  of  the  part  may  at 
times  demand  incisions  through  the  deep  fascia.  The  same  precautions 
as  to  temperature  must  be  taken  here.  The  constitutional  treatment  will 
V)e  less  stimulating,  yet  supporting,  and  the  local  management  of  the 
dead  part  will  be  the  same  as  given. 


100  A  TEXT-BOOK   ON   SURGERY. 

When  all  the  vessels  are  subjected  to  pressure,  it  is  essential  to  relieve 
the  constiiction  as  early  as  possible.  However,  the  vitality  of  an  organ 
seemingly  dead  should  not  be  despaired  of,  since  restoration  of  function, 
after  prolonged  strangulation  is  occasionally  witnessed.  \Vlu'n,  as  in 
phlegmonous  or  other  intianimation,  the  tension  is  so  extreme  that  gan- 
grene is  threatened  by  pressure  of  the  exudation  ui)on  the  c;ii)illarios  or 
larger  vessels,  free  incisions  should  be  made,  parallel  with  the  general 
direction  of  the  vessels,  and  of  sufficient  depth  and  number  to  relieve  the 
tension.  AVhen,  as  in  threatened  gangi-ene  of  a  finger,  the  swelling  is 
severe,  increasing,  as  it  does,  the  tension  of  the  organ  and  its  own  destruc- 
tion, incisions  are  also  demanded,  and  may  prevent  mortification  before 
the  constricting  body  is  removed. 

Chronic,  Senile,  or  Dry  Gangrene. — Dry  gangrene  may  occur  in  any 
period  of  life.  Although  children  and  adults  are  occasionally  attacked, 
it  is  in  the  vast  majority  of  cases  a  disease  of  the  aged  ;  hence  it  is  called 
senile  gangrene. 

Calcareous  degeneration  of  the  arteries,  which  is  given  as  a  cause  of 
senile  gangrene,  is  of  itself  a  result  of  general  impairment  of  nutrition  ; 
and  it  is  to  this  failure  of  the  heart  to  force  the  proper  quantity  and 
quality  of  blood  to  the  tissues  that  we  must  look  for  the  cause  of  this 
disease. 

With  a  circulating  fluid  so  deficient  in  nutrition,  and  a  heart  so 
crippled  in  its  action  that  its  function  is  illy  performed,  it  is  not  difficult 
to  understand  that  the  pressure  of  a  shoe,  a  contusion  of  the  foot,  or  the 
lodgment  of  atheromatous  or  calcareous  particles  in  the  terminal  arte- 
rioles or  capillaries,  would  precipitate  a  morbid  process,  scarcely  awaiting 
even  an  accident  for  its  inauguration. 

Symptoms. — In  many  cases  of  dry  gangrene  there  is  no  history  of  an 
injury.  Symptoms  of  constitutional  debility  from  general  imi)airment 
of  nutrition  usually  precede  the  local  expression  of  the  disease.  The 
lower  extremities  are  most  frequently  affected.  The  patient  suffers  at 
times  from  coldness  of  the  hands  and  feet.  Shooting  pains  are  not  infre- 
quently felt,  and  cramps  occur  in  the  muscles  of  the  feet  and  calf  of  the 
leg.  In  exceptional  cases  there  are  none  of  the  above  premonitory  symp- 
toms, the  first  indication  being  the  appearance  of  a  brown  or  black  dis- 
coloration on  the  foot  or  toe,  or  an  insignificant  excoriaticm  may  be  the 
starting-point  of  the  moi-bid  process. 

From  this  the  disease  travels  in  the  direction  of  the  heart  with  vary- 
ing rapidity.  If  the  condition  of  antemia  is  extreme,  there  will  be  no 
inflammatory  discoloration  in  front  of  the  advancing  line  of  mortification, 
the  skin  changing  from  its  nonnal  pale  color  into  the  black,  dead  hue  of 
the  mummified  part.  The  putrescent  odor  of  wet  gangrene  is  absent, 
and,  instead  of  the  swollen,  doughy  appearance  of  acute  mortification, 
the  part  involved  becomes  hard  and  shriveled.  The  march  of  the  disease 
is  comjiaratively  slow,  and  not  infrequently  death  from  exhaustion 
ensues  before  the  line  of  demarkation  is  formed.  In  exceptional  instances 
the  disease  confines  itself  to  the  toes,  or  anterior  part  of  the  foot. 

Treatment. — The  part  affected  should  at  once  be  enveloped  in  cotton- 


t1 


GANGRENE.  101 

batting  and  oil-silk  or  protective,  and  placed  in  a  position  consistent  with 
the  comfort  of  the  patient.  No  operative  procedure  is  justifiable  until  a 
well-defined  line  of  demarkation  is  established,  unless  septic  absorption 
occurs  to  threaten  the  safety  of  the  patient.  The  most  important  treat- 
ment is  directed  to  the  nutrition  of  the  individual  and  the  increased 
vigor  of  the  heart.  Opium,  to  relieve  pain,  is  as  much  of  a  necessity  as 
stimulants  and  food. 

Contagious,  Phagedenic,  or  Ilospital  Gangrene. — Although  this  dis- 
ease occurs  most  frequently  in  hospitals  crowded  with  wounded,  where 
ventilation  and  drainage  are  deficient,  instances  are  recorded  of  outbreaks 
where  the  most  careful  sanitary  regulations  had  been  enforced.  No 
season  of  the  year  offers  an  immunity  from  its  ravages,  although  a  warm, 
moist  atmosphere  is  most  favorable  to  its  development.  It  is  intensely 
contagious.  The  inoculation  may  be  effected  not  only  throiigh  instru- 
ments, sponges,  dressings,  or  the  hands  of  the  attendants,  but  through 
the  medium  of  the  atmosphere.  As  to  its  infectious  character  there 
exists  a  difference  of  opinion.  It  is  held  by  observers  equally  competent 
and  experienced  that  an  abrasion  is  essential  to  the  introduction  of  the 
disease,  and,  on  the  other  hand,  that  it  may  result  from  inhalation  of  the 
geiTOS,  the  vesicle  and  ulcer  appearing  as  a  local  expression  of  the  sys- 
temic infection.  The  epidemics  of  phagedenic  gangrene  may  vary  in 
severity.  Appearing  in  a  malignant  form,  it  suffers  no  wound  to  escape, 
while  less  frequently  only  isolated  cases  may  occur.  While  a  healthy 
condition  of  the  individual  will  favor  a  recovery  from  the  effects  of  this 
malady,  it  affords  no  exemption  from  its  inoculation  upon  the  wounded 
surface.  It  may  be  ingrafted  ujion  any  form  of  abrasion,  at  any  stage  in 
the  process  of  repair. 

Sgmijtoms. — The  effects  of  this  disease  may  be  studied  as  local  and 
constitutional. 

When  a  recent  puncture,  or  fresh  and  minute  abrasion,  is  attacked, 
the  first  symptoms  are  the  formation  of  a  vesicle  and  the  appearance  of  a 
limited  zone  of  redness  at  its  base.  The  rupture  of  the  vesicle  gives 
escape  to  a  thin,  serous  fluid,  and  the  excoi-iated  base  becomes  covered 
\vith  a  grayish  mold.  The  infected  part  becomes  painful  and  swollen, 
and,  if  the  disease  is  not  immediately  arrested  in  its  progress,  a  rapid 
dissolution  of  the  tissues  ensues.  The  skin  breaks  down,  leaving  pre- 
cipitous margins  to  the  diseased  area.  The  underlying  tissues  are 
desti-oyed  more  rapidly  than  the  integument,  which  frequently  becomes 
undernuned  to  such  an  extent  that,  if  repeated  careful  explorations  are 
not  made,  the  true  condition  of  the  part  may  escape  observation. 

If  at  the  time  of  inoculation  the  wound  is  covered  with  a  graniilating 
surface,  it  will  be  observed  that  at  various  points  the  granulation-tissue 
loses  its  florid  color,  becomes  pale,  and  this  pallor  is  immediately  followed 
by  the  appearance  of  a  grayish-black  mold,  which  rapidly  spreads  over 
the  entire  wound.  The  normal  secretion  gives  way  to  a  dirty,  watery 
discharge.  The  odor  emanating  from  the  gangrenous  sore  is  exceedingly 
offensive  and  peculiar. 

The  constitutional  symptoms  are  those  of  acute  septicaemia,  and  are 


102  A   TEXT-BOOK   ON   SURGERY. 

wholly  dependent  npon  the  absorption  of  poisonous  material  at  the  seat 
of  the  disease  —  headache,  jiain  in  the  part  affected,  irregular  febrile 
movement,  hectic  suffusion,  followed  by  cold  perspiration,  rapid  and 
weak  pulse,  and,  as  the  malady  ])rogresses,  great  prostration,  diarrhoea, 
delirium,  and  death,  which  results  usually  in  from  one  to  three  weeks. 

Pror/nosis. — Once  the  dread  and  scourge  of  civil  as  well  as  military 
hospitals,  contagious  gangrene,  in  the  achievement  of  modern  suigery, 
has  taken  its  place  as  a  complication  of  a  wound  annoying  and  painful 
rather  than  dangerous  to  the  life  of  the  individual.  A  fatal  termination 
may  ensue  when  the  wound  is  contiguous  to  important  vessels,  where 
haemorrhage  may  occur,  either  from  death  of  the  tissues  from  gangrene, 
or  their  destruction  by  caustics  in  the  effort  to  arrest  the  disease.  The 
prognosis  may  also  be  grave  when,  from  the  nature  of  the  injury,  the 
deeper  portions  of  the  slough  can  not  be  reached,  and  drainage  secured. 
Under  such  conditions  death  is  apt  to  ensue  from  septic  absorption. 

Treatment. — As  soon  as  a  wound  is  attacked  with  gangrene  it  should 
be  mopped  with  pure  bromine  or  undiluted  nitric  acid.-  Care  should  be 
taken  not  to  allow  the  escharotic  to  run  over  and  ])urn  the  uninvaded 
skin.  If  the  neighboring  integument  is  protected  with  vaseline  this  acci- 
dent may  be  prevented.  If  the  disease  has  been  in  progress  for  one  or 
two  days,  and  the  wound  is  covered  in  with  the  pulpy  mold  peculiar  to 
this  malady,  the  entire  wound  should  be  scraped  out  with  a  Yolkmann's 
spoon,  and  the  acid  or  bromine  thoroughly  applied.  When  the  skin 
has  been  undermined,  or  the  deeper  tissues,  as  the  miiscles,  involved,  free 
incisions  should  be  made  in  order  to  expo.se  every  porticm  of  the  diseased 
tissue  to  the  action  of  the  caustic.  After  this  a  plug  of  iodoform  gauze 
should  be  laid  in  the  bottom  of  the  wound,  and  a  pile  of  loose  sublimate 
gauze  (1  to  1,000)  added  to  this.  Where  a  penetrating  wound,  as  a  bullet 
or  puncture,  has  become  infected  under  conditions  that  will  not  permit 
incision,  the  entire  track  of  wounded  tissiie  must  be  subjected  to  the 
process  of  cauterization  and  disinfection.  In  order  to  accomplish  this, 
the  opening  or  openings  of  the  wound  may  be  enlarged,  the  cavity  scraped 
thoroughly  with  sponges  fastened  to  holders,  and  then  the  entire  track 
inundated  with  bromine.  Ether  should  be  administered  to  relieve  the 
pain  of  the  applications,  and  opium  afterward. 

The  constitutional  treatment  looks  to  the  nourishment  of  the  patient. 
The  sanitary  management  of  a  case  is  of  the  greatest  importance.  Isola- 
tion of  the  cases  attacked,  and  the  immediate  removal  of  other  patients 
from  the  same  ward,  tent,  or  locality,  is  urgent.  All  instruments  should 
be  disinfected  in  10-per-cent  carbolic-acid  solution,  or  by  being  submitted 
to  a  red  heat,  and  all  sponges,  dressings,  etc.,  instantly  burned.  The 
floor,  walls,  and  ceiling  of  a  hospital- ward  in  which  a  case  of  phagedenic 
gangrene  has  occuiTed  should  be  washed  and  irrigated  wiih.  1  to  1,000 
sublimate  solution,  and  the  mattresses  burned. 


CHAPTER  VIII. 

AMPUTATIONS. 

An  amputation  is  the  complete  separation  of  any  projecting  organ  or 
member  from  the  body.  While  the  term  may  be  applied  to  operations 
in  which  the  breast,  penis,  sci-otum,  cervix  uteri,  etc.,  are  cut  away,  by 
long  usage  and  common  consent  it  is  now  restricted  to  removal  of  the 
extremities  or  their  sulxli visions. 

An  amputation  may  be  accidental,  as  when  a  Umb  is  torn,  cut,  or 
crushed  off  by  machinery  ;  natural,  when,  as  in  senile  gangrene  from 
gradual  failure  of  the  heart,  or  pathological  changes  ia  the  arteries,  the 
dead  portion  is  separated  at  the  line  of  demarkation  ;  or  surgical,  when 
scientihcally  perfonned. 

When  in  an  amjiutation  the  line  of  section  is  through  the  substance 
of  the  bone,  the  operation  is  said  to  be  in  continuity,  and  when  through 
an  articulation,  in  conti(/uit)j.  The  removal  of  a  part  which  is  useless  or 
deformed,  the  pi'esence  of  which,  however,  does  not  threaten  the  life  of 
the  individual,  is  called  an  amputation  of  expediency  ;  under  more  urgent 
conditions,  the  operation  is  one  of  necessity.  Amputations  of  necessity 
are  further  subdivided  into  those  after  accident  and  those  after  disease. 

In  amputations  after  accident,  the  period  in  which  the  operation  may 
be  performed  is  divided  into  the  immediate,  primary,  and  secondary. 
An  immediate  amputation  is  done  during  the  prevalence  of  shock,  and 
usually  within  from  two  to  six  hours  after  the  receipt  of  the  injury  neces- 
sitating the  opei'ation  ;  primary,  after  reaction  from  shock,  and  before 
inflammation  is  established — usually  within  twenty-four  hours  after  the 
injury  ;  secondary,  when  performed  after  this  limit,  and  during  the  preva- 
lence of  inflammation. 

The  danger  of  death  after  amputation  depends  chiefly  upon  the 
character  of  the  injury,  and  the  location  of  the  line  of  section.  The 
prognosis  becomes  grave  in  proportion  to  the  exhaustion  of  the  patient 
as  a  result  of  hsemorrhage,  shock,  sepsis,  or  of  any  dyscrasia  or  inter- 
current disease. 

As  to  the  line  of  section^  there  are  practically  no  exceptions  to  the 
law  that  the  rate  of  mortality  is  proportionate  to  the  diameter  of  the  part 
divided  and  the  proximity  of  the  section  to  the  trnnk.  Thus,  amputa- 
tions of  the  lower  extremity  are  more  fatal  than  those  of  the  upper,  those 
of  the  hip  more  fatal  than  through  the  middle  and  lower  third  or  through 
the  leg,  while  the  same  comparison  holds  good  fi'om  the  shoulder  out. 


104  A  TEXT-BOOK   ON  SURGERY. 

As  to  the  age  of  the  patient,  it  may  be  said  that  the  death-rate  gradu- 
ally increases  with  each  decade  of  life. 

Oi)eniti()ns  of  expediency,  when  properly  perfoi-med,  may  be  consid- 
ered as  practical!}^  free  from  danger,  for  the  reasons  that  the  genci-vl  con- 
dition of  the  patient  is  good,  and  the  section  through  clean  and  liealthy 
tissues.  Amputations  after  iwii-mallgnant  (lisease,  such  as  dcstnictive 
artliritis  and  osteitis,  are  conii)arutively  free  from  danger,  jirovidcd  that 
general  sepsis  and  consequent  exhaustion  have  not  occurred  prior  to  the 
operation.  'Amputations  necessitated  by  malignant  neoplasms  aie  espe- 
cially dangerous  only  in  proportion  to  the  degree  of  malignancy  in  the 
tumor,  together  with  the  general  deterioration  of  the  tissues  as  a  result  of 
the  prevailing  cachexia. 

Amputations  after  accident  are  most  fatal,  and  the  statistics  show  that 
primary  operations  are,  in  general,  more  dangerous  than  those  done  in 
the  secondary  period. 

Lastly,  the  value  of  the  bloodless  operation,  together  with  the  safety 
from  inflammation  and  sepsis,  which  a  thorough  knowledge  and  prac- 
tice of  the  antiseptic  metJiod  guarantees,  can  not  be  overestimated  in 
diminishing  the  death-rate  after  amputation.  The  employment  of  Es- 
march's  bandage,  the  deligatitm  of  the  vessels,  the  use  of  sublimate 
irrigation,  and  the  permanent  antiseptic  dressings,  have  been  heretofore 
described. 

Amputations  are  much  less  frequent  now  than  formerly,  and  there  is 
little  doubt  that,  in  the  present  rajjid  advance  in  the  science  of  surgery, 
and  the  greater  perfection  in  its  art,  the  time  is  not  far  removed  when 
amputations  for  other  cause  than  gangrene  will  be  comparatively  rare. 
To  the  consummation  of  this  hope  the  education  of  the  laity  becomes  the 
first  duty  of  the  practitioner.  Very  few  deformities  would  lead  to  the 
necessity  of  amputation  if  in  their  incipiency  the  services  of  a  skillful 
surgeon  were  obtained.  And  this  is  equally  true  of  those  lesions  of  the 
joints  and  bones  for  which  the  necessity  of  amputation  would  be  excep- 
tional if,  at  the  earliest  symptoms  of  disease,  the  proper  treatment  were 
instituted.  Even  when,  from  neglect,  extensive  necrosis  or  destructive 
arthritis  shall  have  occurred,  exsections  of  the  diseased  tissues  should 
always  be  preferred  to  amputation,  notwithstanding  the  shortening  which 
may  result,  for  a  stiff  joint  and  a  short  limb,  capable  of  even  limited 
motion  and  body  support  or  function,  is  far  better  than  the  most  perfect 
prothetic  apparatus. 

Malignant  or  non-malignant  neoplasms  often  lannecessarily  lead  to 
amputati(m  when  an  early  and  wide  excision  of  the  growth  would  in 
great  probability  have  arrested  the  disease  and  saved  the  limb.  In  cases 
even  of  doubtful  diagnosis,  in  the  earlier  days  of  the  appearance  of  the 
tumor,  the  benefit  of  the  doubt  should  be  given  to  the  ultimate  safety  of 
the  part,  and  the  knife  freely  used. 

As  to  the  propriety  of  performing  an  immediate  amputation  after  in- 
jury, it  is  exceedingly  questionable.  The  conditions  which  would  justify 
this  practice  will  rarely  prevail.  Even  primary  operations  should  be 
exceptional  in  this  age  when  the  value  of  drainage  is  so  fully  appreciated, 


AMPUTATIONS.  105 

and  the  danger  of  sepsis  diminished  by  the  faithful  employment  of  that 
cleanliness  which  is  found  in  the  antiseptic  method. 

In  extensive  lacerations  of  the  soft  parts  and  fracture  of  bone,  the 
indications  in  treatment  entitled  to  the  first  consideration  may  be  stated 
as  being :  arrest  of  haemorrhage  by  the  catgut  ligature  or  direct  pressure, 
through  drainage,  iodoform  and  sublimate  dressings,  fixation  of  the  part 
— usually  in  an  elevated  swing  (Figs.  7,  114,  164)— with  constant  irriga- 
tion as  a  last  resort.  If,  despite  all  these  precautions,  septicfemia  should 
occur,  or  gangrene  result,  amputation  is  necessitated. 

The  first  general  law  in  performing  an  amputation  is  that  no  more  of 
the  member  should  be  cut  away  than  is  absolutely  essential  to  the  safety 
of  the  patient.  Anj^  exception  to  this  rule  will  be  given  along  with  the 
special  amputation  to  which  it  may  apply. 

While  it  is  always  desirable  to  make  an  amputation  wound  throiagh 
healthy  tissues,  this  should  not  be  done  at  the  expense  of  the  part  in- 
volved, for  tiaps  made  through  inflamed  tissues  heal  readily  enough,  and 
offer  no  element  of  danger  to  the  life  of  the  patient  when  properly  drained. 

Method  of  Operating. — In  making  an  amputation,  no  matter  what 
shape  the  incisions  may  take,  the  jjoint  of  first  importance  is,  that  the 
soft  parts  which  are  to  forai  the  covering  or  hood  for  the  bone  shall  be 
long  enough  to  be  free  from  tension  after  the  sutures  are  adjusted  and 
the  dressing  completed.  It  is  always  wiser  to  err  on  the  safe  side,  and 
make  the  flaps  a  little  too  long  than  too  short,  for  it  is  a  simple  matter  to 
trim  them  down  to  the  proper  length.  In  doing  this,  some  allowance 
must  always  be  made  for  the  additional  retraction  which  occurs  after  the 
tourniquet  is  removed  and  consciousness  is  restored. 

The  direction  of  the  line  of  incision,  and  the  shape  of  the  cuflf  or  tiaps, 
will  depend  in  part  upon  the  shape  of  the  limb  at  the  point  of  section,  as 
well  as  the  condition  of  the  soft  tissues  from  which  the  covering  is  to  be 
made. 

While  the  rale  just  given — namely,  to  have  plenty  of  flap — is  essential, 
it  is  scarcely  of  less  importance  to  guard  against  all  interference  with 
the  nutrition  of  the  integument  which  covers  in  the  stump.  To  this  end 
rough  handling,  and  the  employment  of  strong  and  irritating  solu- 
tions, should  be  avoided.  In  general,  that  flap  will  unite  most  readily, 
and  prove  most  satisfactory,  in  the  formation  of  which  the  normal  rela- 
tion of  the  skin  to  the  subcutaneous  soft  tissues  is  least  disturbed. 
Following  this  rule,  preference  should  be  given  to  solid  flaps  which  are 
composed  of  all  the  soft  tissues  lifted  from  the  periosteum.  Again,  it  is 
always  preferable  to  divide  the  skin,  muscles,  vessels,  and  other  soft 
tissues  squarely  across,  and  not  ebliqnely,  as  must  of  necessity  be  done 
in  forming  flaps  by  transfixion.  This,  the  solid-flap  method,  is  applica- 
ble to  most  amputations — as  will  be  shown  farther  on — in  patients  of 
slight  muscular  development,  and  ^\ith  little  or  no  siibcutaneous  areolar 
tissue,  for  a  closely  dissected  skin-flap  in  this  class  of  cases  is  always 
objectionable,  on  account  of  the  danger  of  sloughing.  When  the  soft 
tissues  at  the  line  of  section  are  very  thick,  and  when  the  integument  is 
well  guarded  by  a  fair  quantity  of  underlying  fat,  the  solid  flaj)  will  at 


106  A  TEXT-BOOK  ON  SURGERY. 

times  be  found  to  be  objectionable,  and  flai)s  composed  of  skin  and  tlic 
subcutaneous  tissues,  down  to  the  deep  fascia,  preferal^le. 

The  metliods  of  amputating  an  extremity  may  therefore  be :  First, 
solid  flap,  composed  of  all  the  soft  tissues  lifted  from  the  periosteum  ; 
second,  skin-flap,  composed  of  the  integument  and  the  subcutaneou;} 
tissue,  down  to  the  deep  fascia  ;  third,  mixed  flap,  composed  of  skin  on 
one  side,  and  of  all  the  soft  tissues  on  the  other. 

Flaps  composed  of  the  integument,  together  with  all  the  underlying 
soft  tissues,  may  be  made  by  the  circular  method,  forming  a  single  cuff, 
or  by  the  double-beveled  flap,  made  by  transfixion  and  cutting  from 
within  out,  or  by  cutting  directly  down  from  the  surface. 

Circular  Solid  Flap,  with  Perpendicular  Slit — First  Mrfliod. — Sup- 
posing that  the  section  is  through  the  right  humerus,  at  tlie  juiu'tion  of 
the  middle  and  lower  thirds,  proceed  as  follows :  Place  the  patient  so 
that  the  member  to  be  removed  projects  well  over  the  edge  of  the  table. 
Envelop  the  rest  of  the  body  with  necessary  wraps,  and  cover  all  in  with 
rubber  cloth,  so  arranged  that  the  irrigating  fluid  wOl  not  reach  any  por- 
tion but  the  aiTU.  If  folded  proj^erly  into  a  trough-shaj)e,  the  solution 
will  be  conducted  into  a  vessel  beside  the  table.  The  entire  hand  and 
arm  should  be  washed  with  soap  and  water,  cleanly  shaved  for  six  inches 
above  and  below  the  line  of  section,  and  in  succession  washed  with  sul- 
phuric ether  and  a  solution  of  corrosive  sublimate  (1  to  3,000).  If  any 
inflamed  or  suppurating  surfaces  are  exposed,  close  to  the  line  of  am- 
putation, these  should  be  irrigated  with  sul)limate,  and  thorotighly 
scraped  out  and  again  irrigated,  after  the  Esmarch  bandage  has  been 
applied.  Towels  wet  in  warm  (1  to  3,000)  sublimate  solution  are  now 
wi'apped  about  the  hand,  forearm,  and  arm,  the  extremity  elevated,  in 
order  to  facilitate  gravitation  of  blood  toward  the  center,  and  the 
Esmarch  bandage  tightly  applied,  from  the  finger-tips  to  the  axilla.  As 
soon  as  the  constricting  band  is  secured  at  or  close  to  the  axilla,  the 
bandage  beyond  is  removed,  and  all  exposed  parts  not  in  the  field  of 
operation  covered  with  fresh,  warm  sublimate  towels.  The  assignment 
of  positions  about  the  table  are  shown  in  Fig.  154.  The  operator  stands 
so  that  the  non-preferred  hand  (usually  the  left)  grasps  the  member 
between  the  line  of  section  and  the  trunk,  and  thus  steadying  the  tissues, 
the  instruments  are  used  by  the  right  hand.  The  first  assistant  stands 
where  he  can  most  easily  reach  the  wound,  for  purposes  of  sponging, 
retracting  flaps,  etc.  ;  the  second  is  placed  directly  between  the  operator 
and  the  instrument-trays ;  the  tlilrd  attends  to  the  anaesthetic,  holding 
the  cone  so  that  the  expired  air  and  ether  vapor  will  not  annoy  the  opera- 
tor ;  the  fourth  holds  the  member  to  be  removed,  grasping  the  elbow  with 
his  left  hand,  and  the  wrist  and  f oreann  with  the  right ;  the  fifth  attends 
to  the  irrigator  ;  the  sixth  and  seventJi  are  intrusted  with  the  sponges,  one 
of  whom  holds  in  one  hand  a  basin  of  freshly  squeezed  out  sponges,  and 
in  the  other  a  second  basin  for  those  which  have  become  soiled  or  bloody. 
Both  should  be  within  easy  reach  of  the  first  assistant.  The  duty  of  the 
seventh  assistant  is  chiefly  to  rinse  the  sponges,  procure  fresh  towels,  etc. 
"VVlien  possible,  it  is  always  convenient  to  have  two  extra  orderlies  or 


AMPUTATIONS. 


107 


nurses — one  for  waiting  upon  the  ansesthetizer,  and  the  other  for  purposes 
of  general  utility. 

Operation — First  Method. — With  the  left  hand  slide  the  skin  toward 
the  shoulder,  and  at  a  point  sufficiently  below  the  line  of  section  through 


I'lG.  154. 


the  bone  to  afford  ample  covering  (something  more  than  one  haK  the 
diameter  of  the  Umb,  measured  where  the  saw  is  to  be  applied),  make  a 
circular  cut  around  the  member,  dividing  the  skin  and  subcutaneous  fat 
down  to  the  deep  fascia  (Fig.  155).  The  upper  margin  of  this  wound  is 
retracted  toward  the  body  as  far  as  possible,  and,  at  this  line  of  retraction. 


Fig.  155. — Circular  incUion  tlirouofh  the  skin. 


with  the  same  knife  (a  good  scalpel  is  preferable"*  cut  all  the  remaining 
soft  tissues  squarely  down  to  the  periosteum  (Fig.  15(3).  An  incision  is 
next  made,  parallel  Avith  the  axis  of  the  humerus,  on  the  outer  (or  non- 
vascular) side  of  the  arm,  dividing  everything  to  the  periosteum,  and 
extending  up  to  the  point  where  the  bone  is  to  be  sawn  through  (Fig. 


108 


A  TEXT-BOOK   ON   SURGERY. 


157).     With  a  dry  dissectdrfthe  handle  of  the  scalpel  will  usually  suffice) 
— ouly  using  a  sharp  instrument  where  necessary— lift  the  tissues  closely 


fiQ.  156. — TLe  same,  contiuuoil  down  to  the  bone. 


from  the  periosteum  until  the  solid  cuff  can  be  folded  back  (without 
over- traction  or  bruising)  sufficiently  to  expose  the  bone  at  the  point  of 


Fio.  157.— Lougitudinal  incision. 


section.     A  towel  moistened  in  1  to  3,000  sublimate  (or  a  split  retractor) 
is  now  wrapped  about  the  cuff  or  flap  and  the  bone,  so  that  the  tissues 


which  compose  the  flap  may  not  be  bruised  or  torn  by  the  saw,  and  at 
the  same  time  be  protected  from  having  the  bone-dust  scattered  over 
the  cut  surface  (Fig.  158). 


AMPUTATIONS.  109 

In  applying  the  saw,  it  is  best  to  place  the  center  df  this  instrument 
against  the  bone  close  up  to  the  retractor,  always  holding  its  blade  in 
such  relation  to  the  bone  that  the  sawn  surface  will  be  perpendicular  to 
the  axis  of  the  bone.  A  few  short  strokes  will  suffice  to  cut  a  trench  or 
hold  for  the  saw,  which  may  then  be  more  rapidly  used.  The  operator 
steadies  the  member  with  his  left  hand  on  the  central  side  of  the  wound, 
while  the  assistant  holds  the  exti"emity.  As  the  section  is  about  being 
completed,  he  is  directed  to  cease  all  traction,  simply  supporting  the 
weight  of  the  limb,  and  thus  splintering  may  be  avoided.  The  last  few- 
strokes  of  the  saw  should  be  very  lightly  and  carefully  made,  to  avoid 
the  same  accident.  The  retractor  is  allowed  to  remain  after  the  bone  is 
divided  and  the  amputated  part  removed,  and  until,  with  a  bone-cutter 
or  cartilage-knife,  the  circumference  of  the  cut  surface  is  smoothed  and 
rounded  off.  In  doing  this,  the  force  applied  should  always  be  toward 
the  center  of  the  bone,  to  prevent  stripping  up  the  periosteum  or  splin- 
tering. 

The  practice  of  dissecting  a  periosteal  cuff,  at  one  time  recommended 
for  the  purpose  of  covering  over  the  end  of  the  bone,  is  now  justly 
abandoned.  While  it  succeeded  in  some  instances,  in  many  it  gave  rise 
to  great  annoyance,  necessitating  a  second  operation  on  account  of  ex- 
ostosis or  necrosis.  The  retractor  is  now  removed,  the  stump  imgated, 
and  the  surface  then  thoroughly  dried  with  sponges,  so  that  the  vessels 
may  be  secured.  The  larger  arteries  and  veins  may  be  readily  found, 
and  the  ends  seized  with  the  forceps.  All  the  tissues  should  be  care- 
fully stripped  from  these  by  a  blunt  instrument  (grooved  director), 
and,  when  the  catgut  is  thus  aj^plied,  the  operator  is  sure  that  no  nerve- 
tissue  is  caught  along  with  the  vessel.  For  the  larger  vessels  the  double 
or  friction  loop  (Pig.  113)  should  be  employed  ;  the  single  knot  wiU  suffice 
for  the  smaller.  When  ligatures  have  been  applied  to  all  the  vessels 
which  can  be  recognized  by  the  eye,  other  "  bleeding  points "  may  be 
discovered  by  grasping  the  limb  a  few  inches  above  the  line  of  section 
and  then  forcing  out  the  small  quantity  of  blood  which  remains  after 
Esinarch's  bandage.  As  it  oozes  out  over  the  cut  surface,  its  point  of 
exit  may  be  caught  up  by  the  broad-jawed  forceps,  and  in  doing  this 
it  is  usually  necessary  to  pick  up  a  small  bit  of  whatever  tissue  may 
be  immediately  about  the  vessel.  In  tying  a  catgut  thread  around 
these  vessels,  the  loop  should  be  tightened  upon  the  jaws  of  the  instru- 
ment on  the  slope  nearest  the  point,  for  as  it  is  further  tightened  it 
grasps  the  metal  closely  and  slides  over  the  end,  including  no  tissue 
but  that  already  in  the  grasp  of  the  forceps.  Having  proceeded  thiis  far, 
the  stuni])  being  elevated,  the  wound  should  be  filled  with  clean  Avarm 
sponges,  covered  with  sublimate  towels,  and  firmly  compressed  by  the 
operator  while  the  assistant  removes  the  tourniquet.  After  waiting  two 
or  three  minutes  for  the  vessels  to  fill,  one  by  one  the  sponges  are  care- 
fully removed,  and  any  bleeding  points  caught  with  the  forceps.  "When 
these  shall  have  been  tied,  the  wound  should  again  be  flooded  with  warm 
1  to  3,0()()  sublimate,  packed  with  sponges  well  squeezed  out,  the  whole 
covered  in  with  sublimate  towels,  and  bimanual  compression  employed 


110  A  TEXT-BOOK   ON   SURGERY. 

for  five  mimites,  when  it  will  be  seen  that  all  bleeding  has  i)ractically 
ceased.  The  general  oozing,  especially  that  from  the  end  of  the  bone, 
may  be  controlled  by  pressure  and  position  after  the  sntnrcs  are  applied. 
In  sewing  up  the  cuff,  alternate  deep  and  superlicial  sutures  should  be 
employed ;  the  former,  about  half  an  inch  apart,  should  enter  the  skin 
from  one  half  to  three  fourths  of  an  inch  from  the  edge  of  the  wound, 
pass  about  the  same  de2)th  through  all  the  tissues,  and  emerge  at  the 
same  distance  from  the  wound  on  the  opposite  side.  The  intervening 
row  should  be  half  way  between  the  deeper  sutures,  and  sliotdd  be  intro- 
duced to  a  depth  of  one  fourth  of  an  inch.  In  tying  the  sutures  the 
double  or  friction  knot  should  be  employed  for  the  first  loop,  for  this 
holds  and  keeps  the  edges  from  separating  while  the  second  knot  is  being 
tied.  The  knots  should  be  kei)t  to  one  side  of  the  line  of  ajjposition.  A 
considerable  degree  of  care  is  essential  in  bringing  the  edges  nicely  and 
accurately  in  apposition,  for  if  the  skin  is  infolded  and  the  epidermal 
surfaces  brought  in  contact,  bad  union  will  result,  and  the  same  is  true 
if  any  of  the  subcutaneous  tissues  project  between  the  edges.  As 
the  threads  are  being  tightened,  infolding  may  be  obviated  by  lifting 
the  edges  with  a  grooved  director,  while  the  same  instrument  may  be 
employed  to  push  any  projecting  fat  or  other  tissues  back  under  the 
skin.  In  tying  the  knots,  the  degree  of  traction  should  just  be  suffi- 
cient to  bring  the  plane  surfaces  of  the  wound  together  without  wrink- 
ling. The  drainage-tubes  should  be  inserted  as  the  wound  is  being 
closed,  and  should  be  numerous  enough  to  drain  the  cuff  at  all  points. 
In  clean  amputations  Neuber's  bone-drains  should  always  be  used.  In 
cutting  through  inflamed  or  infiltrated  tissues,  the  rubl)er  tubes  are  safer. 
If  (as  is  preferable)  the  stump  is  kept  elevated  after  the  operation,  it 
will  be  necessary  to  bring  at  least  one  of  the  tubes  out  at  the  upper  end 
of  the  longitudinal  incision,  while  another  may  project  at  the  tip  of  the 
stump.  No  matter  what  style  of  flap  is  used,  the  tubes  should  always 
lead  from  the  deepest  portion  f)f  the  wound,  and  have  exit  at  such 
declination  that  the  free  outflow  of  all  fluids  will  take  place  into  the  dress- 
ings. A  safety-pin  should  be  passed  through  one  side  of  the  tube  to 
prevent  its  being  pressed  into  the  wound  by  the  bandaging,  or  a  suture 
may  serve  to  hold  it  in  position.  The  nozzle  of  the  irrigator  should  now 
be  introduced  into  one  of  the  tubes  and  the  cuff  flooded  until  the  water 
runs  out  clear  and  until  the  entire  flap  has  been  well  distended.  The 
excess  of  the  solution  is  squeezed  out,  a  strip  of  iodoformized  gauze  is 
wound  around  the  tubes  (not  obstructing  their  caliber),  and  carried  along 
the  line  of  approximation,  extending  about  three  fourths  of  an  inch  on 
either  side.  The  stump  is  now  wiped  ofl"  with  sponges  and  immedi- 
ately enveloped  with  sublimate  gauze  to  the  thickness  of  about  one  inch. 
This  should  be  applied  in  layers,  starting  from  well  above  the  end  of  the 
stump,  by  carrying  a  layer  around  the  limb,  and  following  this  A\ith  a 
second,  which  overlaps  the  first  about  two  inches,  and  so  on  until  the 
last  layer  projects  well  beyond  the  end  of  the  stump.  Over  the  end  a 
large,  thick  sheet  of  gauze  is  laid.  A  layer  of  absorbent  cotton,  about 
one  inch   thick,   is   now  wrapped  ai-ound  and  over  the  end,   and  this 


AMPUTATIONS. 


Ill 


enveloped  by  a  large  sheet  of  rubber-tissue  protective.  A  roller  is  car- 
ried over  all  to  hold  the  dressing  in  place,  and  to  make  compression 
sufficient  to  arrest  oozing.  It  is  impossible  to  say  how  much  pressure 
should  be  employed,  since  this  knowledge  can  only  come  from  practice, 
but  the  bandage  should  be  fairly  tight.  Over-pressure  at  the  tip  should 
be  avoided,  especially  where  the  iiap  folds  down  on  the  end  of  the  bone. 
As  the  last  bandage  is  l)eing  applied,  a  short  splint,  the  end  of  which 
projects  a  couple  of  inches  beyond  the  stump,  should  be  inserted.  This 
steadies  the  limb,  and  is  useful  in  keeping  the  stump  elevated,  especially 
when  an  amputation  is  made  near  the  trunk.  If  the  last  roller  is  made 
wet  before  being  applied,  it  will  be  less  liable  to  slip. 

Such  a  dressing,  under  the  strict  antiseptic  method,  is  not  usually 
removed  before  the  tenth  or  twentieth  day,  and  in  the  majority  of  cases 
where  an  amputation  is  made  through  comparatively  healthy  tissues  a 
single  dressing  is  sufficient.  The  indications  for  its  removal  are  haemor- 
rhage of  an  alaiTning  nature,  great  pain,  high  febrile  movement  (not 
counting  the  reactionary  fever  which  follows  within  twenty-four  hours 
after  the  operation),  and  excessive  discharge  beyond  the  zone  of  anti- 
sepsis, with  decomposition. 

Ordinary  bleeding  may  be  controlled  and  permanently  arrested  by  an 
extra  tight  roller,  or  Esmarch  bandage,  loosely  applied  for  an  hour  or 
two.  A  rise  in  the  temperature  of  102°  to  103°  on  the  second  day,  or 
later,  suggests  iniiammation  and  sepsis.  Lastly,  when  the  serum  or  tiuids 
from  the  stump  seep  under  the  dressing  and  decompose,  the  change  is 
necessitated  on  account  of  the  odor.  "When  a  new  dressing  is  made,  the 
same  antiseptic  precautions  should  be  employed. 

Second  Method — Oblique  Solid  Flaps  by  Transfixion. — Seize  the  ann 
with  the  left  hand  so  that,  as  all  the  soft  tissues  are  pinched  up  on  its 
anterior  aspect,  the  thumb  and  index-finger  on  opposite  sides  will  be  just 
above  the  point  at  which  it  has  been  decided  to  divide  the  bone.  The 
point  of  a  long  knife  is  pushed  from  the  outer  side  (right  arm)  horizon- 
tally down  until  it  impinges  upon  the  center  of  the  bone ;  the  handle  is 
depressed,  the  point  grazes  over  the  bone,  the  handle  is  now  elevated,  and 


flaps  by  transfixion. 


the  point  made  to  project  exactly  opposite  and  on  the  same  plane  with  the 
point  of  entrance  (Fig.  159).  By  a  long  sawing  movement  the  knife  is  made 
to  cut  directly  along  the  bone  until  within  from  one  half  to  one  inch  of  the 


112  A  TEXT-BOOK   ON  SURGERY. 

limit  of  the  flap,  when  it  is  turned  rather  abruptly  out,  shaping  a  blunt, 
rounded  flap.  This  is  held  back  by  the  operator's  left  liand,  the  point  of 
the  knife  is  insinuated  between  the  muscles  and  the  bone,  is  made  to 
glide  along  the  posterior  surface  of  the  bone,  and  to  come  out  at  or  very 
near  the  periosteum  on  the  opposite  side.  A  second  symmetrical  flap  is 
made  in  the  same  way  as  the  first.  The  retractor  is  applied,  and  tiie 
operation  and  dressing  completed  as  before. 

In  making  an  amputation  by  transfixion,  it  is  usually  advised  to  cut 
the  non-vascular  flap  first ;  but,  with  a  safe  tourniquet  applied,  this  pre- 
caution is  unnecessary. 

Third  Method — Oblique  Solid  Flaps,  hy  cutting  from  the  Surface. — 
Cutting  from  the  surface  toward  the  bone,  the  first  crescentic  incision  out- 
lines one  flap  and  goes  down  to  the  deep  fascia  (,Fig.  16U).    After  the  skin 


Fio.  160. — Oblique  BoUd  flaps,  made  by  cutting  downward  from  tlic  skin. 


retracts,  the  muscles  and  remaining  soft  tissues  are  divided  from  its  edge 
obliquely  down  to  the  point  of  section  through  the  bone.  The  opposite 
flap  is  made  in  the  same  manner,  and  the  operation  completed  as  before. 


Skin- Flaps  —  Circular,  Modified  Circular,  Opal,  Douhle  Crescentic, 

and  Double  Rectangular. 

First  Method— Circular. — Before  commencing  the  incision,  grasp  the 
arm  fii'ndy  near  the  line  of  incision,  and  slide  the  integument  upward  as 
far  as  it  will  go.  In  doing  this  operation,  a  good  scalpel  is  preferable  to 
the  long  knife.  The  incision  should  go  straight  down  to  the  fascia  which 
covers  the  muscles,  and  directly  around  the  limb  by  successive  strokes  with 
the  scalpel,  so  that  the  radius  of  the  circle  described  will  be  at  an  angle  of 
90°  with  the  axis  of  the  humerus  (Fig.  161  a).  When  this  is  completed, 
catch  the  edge  of  the  flap  with  a  mouse-tooth  dissecting-forceps,  put  the 
connective  tissues  which  attach  it  to  the  fascia  about  the  muscles  on  the 
stretch  by  pulling  the  sldn  upward,  and  with  well-directed  strokes  or 
touches  with  the  point  of  the  knife,  which  should  be  kept  from  wounding 
the  skin,  raise  the  flap  throughout  the  entire  circumference  of  the  wound. 
As  this  dissection  proceeds,  the  loosened  sleeve  of  integument  may  be 
roEed  up  until  the  point  where  the  muscles  and  bone  are  to  be  divided  is 
reached  (Fig.  161  b).  Just  at  the  margin  of  the  reflected  flap  the  soft  tis- 
sues are  now  divided  straight  down  to  the  bone,  the  line  of  section  being 


AMPUTATIONS. 


113 


perpendicular  to  the  axis  of  the  limb.     The  periosteum  should  next  be 
cut  thi-ouo;h  in  the  circumference  of  the  bone  where  the  saw  is  to  enter. 


Second  Method — Modified  Circular. — The  foregoing  method  should 
always  be  modified  by  a  pei-pendicular  incision  through  to  the  muscles, 
since  this  not  only  renders  the  dissection  more  rapid,  but  does  away  with 
the  unnecessary  bruising  to  which  the  unspUt  cuff  is  subjected  as  it  is 
roUed  upon  itself. 

Third  Method — Oval.— It  not  infrequently  occurs  that  the  condition 
of  the  soft  parts  near  the  line  of  amputation  will  not  permit  of  an  incision 
directly  around  the  limb  without  a  too  great  sacrifice  of  the  member. 
Under  such  circumstances,  an  oval  or  elliptical  incision  may  be  made, 
and  in  this  way  integument  enough  secured  to  cover  in  the  stump.  The 
longitudinal  slit  may  be  added  to  this  operation. 

Fourth  Method — Double  Crescentic. — The  circular  operation  may  be 
further  modified  by  making  two  crescentic  skin-flaps  of  equal  size,  the 


Fig.  1G2.— (After  Esmarch.) 


bases  of  these  being  at  the  line  of  section  of  muscle  and  bone.    The  same 
precautions  as  given  above  are  necessaiy  to  secure  enough  integument 
to  form  a  hood  for  the  stump  (Fig.  162). 
8 


114 


A  TEXT-BOOK   ON   SURGERY. 


Fifth  Method — Double  Rectangular. — The  first  step  is  to  po  around 
the  limb  just  as  if  a  circular  operation  were  intended.  This  being  done, 
two  inoisions,  one  on  either  side  and  exactly  opposite  to  each  other,  are 
made  perpendicular  to  the  circular  cut,  and  extending  up  the  litnb  to  a 
point  on  a  level  with  the  line  of  section  through  the  muscles  and  bone 
(Fig.  163).    The  two  flaps  are  now  dissected  up  to  this  line,  and  the  ampu- 


v^^^^^^- 


tation  completed  as  before.  The  commendable  features  of  this  procedure 
are  the  rapidity  with  which  it  may  be  accomplished,  the  small  degree  of 
violence  inflicted  in  manipulating  the  flaps,  and  the  readiness  with  which 
a  stump  is  drained  when  the  proximal  angles  of  the  lateral  incisions  are 
used  as  outlets  for  the  tubes. 

Mixed  Flaps,  composed  of  integument  alone  on  one  side  and  of  all 
the  soft  tissues  on  the  other,  are  the  least  commendable  of  all  meth- 
ods. The  proper  apposition  of  surfaces  so  uneven  is  difficult.  When 
from  any  cause  this  operation  is  adopted,  care  must  be  taken  to  give 
proper  support  to  the  heavy  solid  flap  to  prevent  dragging  upon  the 
sutures. 

Resume. — The  solid  flaps  should  be  prefeiTcd  to  the  sMn  flaps,  for 
the  reasons  that  the  nutrition  of  the  skin  is  least  disturbed  by  this  method. 
In  thin  and  emaciated  subjects,  and  in  the  arm  and  thigh  regions  (as  will 
be  seen  hereafter),  it  is  especially  applicable.  In  limits  of  large  diameter 
and  a  goodly  quantity  of  subcutaneous  tissue,  the  skin-flaps  are  prefer- 
able, since  a  covering  under  such  conditions  can  be  ol)tained  with  less 
sacrifice  in  the  length  of  the  bone.  Of  the  solid  flaps,  the  circular  method 
is  better  than  the  oblique,  since  it  divides  all  the  tissues  squarely.  In 
making  oblique  flaps,  transfixion  is  better  than  cutting  from  without 
inward.  Of  the  skin-flaps,  the  circular  with  a  single  longitudinal  incision 
should  be  preferred  to  the  other  methods  where  the  limb  is  not  very 
large ;  the  double  rectangular  flaps  where  the  stump  is  to  be  elevated 
and  there  is  a  large  surface  to  drain. 

Open  Method.— Vs\s.fVL  an  amputation  is  made  through  tissues  infil- 
trated with  pus  or  other  Inflammatory  products,  where,  in  the  judgment 
of  the  surgeon,  the  dangers  of  sepsis  would  be  increased  if  the  wound 
were  closed,  the  open  method  should  be  employed,  with  constant  or  in- 
terrupted ii-rigation. 


AMPUTATIONS. 


115 


Before  the  days  of  antisepsis  the  success  of  this  method  was  thor- 
oughly demonstrated  by  Prof.  James  R.  Wood  and  Prof.  Dennis,  in 
Bellevue  Hospital,  where  the  rate  of  mortality  after  amputations,  in 
wards  which  had  been  recently  vacated  on  account  of  puerjieral  fever, 
was  reduced  to  the  minimum  in  the  history  of  that  hospital.  I  have 
employed  this  method  in  a  number  of  septic  cases  with  great  satisfaction. 


l-'li,.  iw. 


In  performing  the  amputation,  the  flaps  must  be  so  shaped  that  in'iga- 
tion  can  be  easily  accomplished  without  moving  the  stump.  A  circular 
cut,  with  a  longitudinal  incision  on  the  upper  surface,  or  bilateral  flaps, 
are  preferable.  When  the  patient  is  put  to  bed  the  stump  is  placed  in 
a  position  suitable  for  drainage,  and  rests  upon  an  oil-cloth  so  arranged 
tluit  the  irrigating  fluid  runs  away  from  the  patient  and  into  a  basin  at 
the  bedside.  The  flaps  should  at  first  be  held  well  open  by  a  wad  of 
sublimate  gauze,  and  the  stump  loosely  enveloped  in  a  thin  layer  of  this 


116  A  TEXT-BOOK   ON   SURGERY. 

niatei-ial,  so  arranged  that,  as  the  water  drips  on  it,  it  will  pass  through 
the  gauze  and  over  the  raw  surface. 

Fig.  164  shows  a  ready-made  irrigator  in  use  in  my  service  at  Mount 
Sinai  Hospital.  A  piece  of  slieet-tin,  about  a  foot  Avide  and  of  any  re- 
quired length,  is  shaped  into  a  trough,  the  bottom  of  which  is  punched 
full  of  holes  with  an  awl.  A  rulibei-  tube  leads  the  water  from  a  tank 
into  this  trough,  from  wliicli  it  trickles  on  to  the  wound  in  any  required 
quantity.  Or,  as  represented  in  the  cut,  the  tube — whicli,  in  tlie  cnse  of 
tlie  ])atient  from  whom  the  drawing  was  made,  conveyed  the  irrigating 
Huid  into  a  suppurating  knee-joint — may  also  be  employed  to  carry  the 
water  into  the  wound. 

Pure  water  should  be  used  for  irrigation.  The  danger  of  absorption 
from  an  extensive  granulating  surface  precludes  the  sublimate  or  carbolic- 
acid  solutions. 

The  only  objection  to  which  this  method  is  open  is  the  slowness  with 
which  the  process  of  repair  goes  on  in  its  employment.  TJiis  is,  however, 
an  objection  of  little  weight  when  the  ultimate  recovery  of  the  patient  is 
secured.  As  soon  as  the  temperature  shows  an  absence  of  sepsis  the  irri- 
gation may  cease,  and  the  granulating  Haps  may  be  approximated  grad- 
ually by  bandages  or  adhesive  strips. 

Special  Amputations. 

Hand  and  Fingers. — A  primary  amputation  of  any  portion  of  the 
hand  is  rarely  if  ever  justifiable.  If  there  is  only  a  small  strip  of  tissue, 
the  integrity  of  which  is  evident,  an  effort  at  the  restoration  of  the  nutri- 
tion and  function  of  the  part  beyond  should  be  attempted.  If  any  doubt 
exists  as  to  the  result,  the  benefit  of  this  should  be  given  to  the  side  of 
conservatism.  It  is  essential  to  arrest  hjemorrhage,  cleanse  the  wounds 
under  strict  antisepsis,  secure  drainage,  and  place  the  parts  in  the  best 
position  for  usefulness  in  case  of  recovery.  Amputation  may  be  done 
when  necessitated  by  gangrene  or  necrosis. 

Fingers  —  Interphalangeal  Operations.— 'Betv^Q^n  the  second  and 
third  ])haianges  of  the  fingers,  proceed  as  follows  :  Flex  the  terminal 
phalanx  at  about  an  angle  of  90°  to  the  axis  of  the  second  bone,  and, 
one  eighth  of  an  inch  anterior  to  the  angle  on  the  dorsal  aspect,  with  a 
small,  shai'p-pointed  scalpel  make  a  transverse  incision,  extending  half 
way  down  the  sides  of  the  finger.  From  this  point  carry  the  incision 
forward,  parallel  with  the  axis  of  the  digit,  to  within  a  quarter  of  an  inch 
of  the  end,  then  across  the  palmar  aspect  of  the  tip  to  the  opposite  side, 
finishing  the  incision  at  the  angle  of 

the  transverse  cut  (Fig.  165).     Dissect  ^-f-—^ ;,: -~ — — - 

the  palmar  flap  up,  keeping  close  to  the  C^'  r^.  ,-'^  /^'W^ 
bone,  lifting  the  flexor  tendon,  with  the 
skin,  back  to  the  articulation ;  divide 
the  tendon  opposite  the  joint,  and  dis- 
articulate. The  flap  is  now  turned 
back,  trimmed  with  the  scissors  to  tit  f'"-  los. 


AMPUTATIONS.  117 

nicely,  and  stitched  with  catgut  sutures.  By  this  method  the  acute 
tactile  sense  of  the  palmar  aspect  of  the  finger  is  preserved,  and  adds 
to  the  usefulness  of  the  stump.  This,  and  other  amputations  of  the 
fingers,  may  be  made  without  general  anaesthesia,  and  with  perfect  in- 
sensibility, by  the  local  use  of  cocaine.  Just  anterior  to  the  second  in- 
terphalangeal  joint  insert  the  needle  of  a  hypodermic  syringe,  and  inject 
in  the  entire  circumference  of  the  finger  twenty  minims  of  a  4-per-cent 
solution  of  cocaine  hydrochlorate.  Two  minutes  later  constrict  the 
root  of  the  digit  with  an  elastic  ligature.  In  this  way  a  painless  and 
bloodless  operation  may  be  performed.  If  the  insensibility  is  not  com- 
plete at  all  points  of  the  incision,  inject  additional  cocaine  in  the  line  of 
the  cut.  Any  danger  of  the  constitutional  effects  of  this  drug  may  be 
obviated  by  squeezing  the  excess  out  thi-ough  the  cut  before  the  sutures 
are  applied. 

In  dressing  these  amputations  the  pressure  on  the  end  of  the  stump 
should  be  light,  for  fear  of  slough  in  the  long  flap.  Usually  no  vessels 
need  to  be  tied.  The  covering  of  cartilage  does  not  reqiiire  to  be  scraped 
or  sawn  off.  When  only  a  slight  jiortion  of  the  anterior  tip  of  the  second 
phalanx  is  involved  in  a  destructive  osteitis  or  injury,  the  remaining 
portion  should  not  be  sacrificed  by  a  disarticulation  at  the  posterior 
interphalangeal  joint.  The  line  of  section  through  the  bone  should  be 
aliout  at  the  junction  of  the  middle  and  anterior  third  of  the  phalanx. 
The  incisions  and  flap  are  made  as  in  the  preceding  operation. 

In  amputation  with  disarticulation  at  the  posterior  interphalangeal 
joint,  flex  at  an  angle  of  90°,  make  a  transverse  incision  over  the  dorsum 
of  the  finger,  from  one  eighth  to  one  fourth  of  an  inch  in  front  of  the 
angle,  which  includes  half  the  circumference  of  the  member.  From  the 
ends  of  this  line  carry  the  incision  directly  forward  on  each  lateral  aspect 
of  the  finger  to  the  crease.on  the  palmar  surface  opposite  the  anterior 
interphalangeal  joint.  A  second  transverse  incision  in  this  fold  com- 
pletes the  rectangular  flap,  which  is  now  dissected  back,  and  the  dis- 
articulation effected  by  placing  the  ligaments  on  the  stretch  and  divid- 
ing these  with  a  narrow,  sharp  scalpel.  If  any  difficulty  is  found 
in  entering  the  joint  from  the  sides  or  front,  it  may  be  easily  done  by 
division  of  the  extensor  tendons  over  the  dorsum,  for  these  take  the 
place  of  posterior  ligaments.  The  method  of  ampiitation,  as  given  for 
the  operation  at  or  near  the  articulation  of  the  first  and  second  pha- 
langes of  the  finger,  applies  also  to  the  thumb  in  amputation  at  the 
last  joint,  or  through  the  first  phalanx,  within  one  fourth  of  an  inch  of 
its  anterior  extremity.  This  plan  of  making  the  flaps  is  far  superior 
to  that  advised  by  Erichsen,  Esmarch,  and  other  authors  who  recom- 
mend cutting  down  and  through  the  joint  from  the  dorsum,  and  then 
forward  along  the  palmar  aspect  of  the  phalanx,  making  the  disarticu- 
lation and  flap  with  a  single  stroke.  In  the  first  place,  this  is  done 
with  no  little  difficulty,  for,  however  thin  the  blade,  the  character  of  the 
joint  will  scarcely  allow  an  easy  passage  to  the  knife.  Secondly,  by 
the  method  of  transfixion  the  flap  is  apt  to  be  cut  too  pointed  and  bev- 
eled at  the  end. 


118 


A  TEXT-BOOK   ON   SURGERY. 


At  the  Metacarpo-PJialangealJoint — Thumb. — AYhen  the  condition 
of  the  soft  parts  -will  permit,  proceed  as  follows  : 

First  Method. — Just  over  the  joint,  and  in  the  middle  of  the  dorsal 
aspect  of  the  thumb,  commence  an  incision  and  carry  it  along  the  surface 
next  to  the  index-finger  until  half  the  circumference  of  the  member  is 
included.  Along  the  dorsal  and  palmar  aspects  carry  parallel  incisions 
forward  until  near  the  interphalangeal  joint,  and  connect  these  by  a 
sti-aight  transverse  cut  across  the  palmar  surface.  Dissect  the  flap  back, 
divide  all  tendons  opposite  the  joint,  disarticulate,  tie  the  dorsales 
pollicis  (one  (m  either  side  of  the  back  of  the  thumb),  and  the  arteria 
princeps  pollicis,  which  lies  along  the  side  of  the  metacarpal  bone  near- 
est the  index-finger  and  divides  into  its  terminal  branches  opposite  the 
metacarpo-phalangeal  joint.  When  the  flap  is  stitched,  the  scar  will  be 
in  good  part  concealed  on  the  ulnar  aspect  of  the  stump. 

Second  Method. — A  transverse  dorsal  incision  is  made  over  the  articu- 
lation, extending  half  around  and  ending  at  opposite  points  on  the  external 
and  internal  lateral  aspects  of  the  thumb.     Parallel  lateral  incisions  are 


Fio.  166. 


Fio.  167. 


Fig.  1G8. 


made  as  far  forward  as  the  interphalangeal  joint,  and  the  anterior  ex- 
tremities of  these  are  joined  by  a  transverse  palmar  cut  (Fig.  166).  The 
end  of  the  metacarpal  bone  of  the  thumb  should  be  left  undisturbed, 
when  not  necrosed,  when  there  is  sound  skin  enough  to  cover  it  in. 
Under  other  conditions  it  may  be  divided  with  a  fine  saw  or  the  exsector. 
The  question  of  the  appearance  of  the  stump  should  be  secondary  to  the 
usefulness  of  the  member.  It  is  especially  important  to  a  laborer  that 
the  end  of  the  metacarpal  bone  of  the  thumb  be  preserved  (Fig.  167). 
When  the  operation  is  performed  upon  one  not  compelled  to  do  manual 
work,  a  more  symmetrical  api^earance  may  be  obtained  liy  an  oblique 
section  of  the  metacarpal  bone  about  half  an  inch  behind  the  articular 
surface.  When  this  is  intended,  the  incision  through  the  skin  should  be 
such  that  the  long  part  of  the  flap  is  obtained  fi-om  the  radial  and  palmar 
aspect  of  the  thumb,  while  the  line  of  sutures  is  situated  well  on  the 
dorsal  surface  of  the  stumj)  (Fig.  168). 


AMPUTATIONS. 


119 


Index-Finger — At  the  Metacarpo-Phalangeal  Joint — First  Method. 
— When  possible,  the  following  method  should  be  adopted,  the  object 
being  to  preserve  the  tactile  sense  and  to  leave  the  scar  less  prominent : 

From  the  ulnar  side  of  the  knuckle,  and  just  over  the  joint,  make 
an  incision  which  extends  from  this  point  forward  as  far  as  the  web 
between  the  index  and  middle  finger,  and,  in  case  of  a  large  knuckle,  a 
little  beyond  this  point  at  the  side  of  the  digit.  From  the  anterior  end 
of  this  incision  make  a  second  cat  directly  across  the  palmar  aspect  of 
the  phalanx  until  the  middle  of  the  radial  side  of  the  finger  is  reached, 
and  complete  the  flap  by  cutting  in  a  straight  line  from  this  point  to  the 
commencement  of  the  first  incision.  When  the  disarticulation  is  com- 
I)leted,  the  dorsalis  and  radiaUs  indicis  arteries,  and  the  external 
digital  branches,  tied  with  fine  catgut,  the  corner  of  the  flap  is  carried 
into  the  receding  angle  on  the  dorsal  surface  of  the  metacarpal  bone 
and  secured  by  sutures.  When  the  head  of  the  metacarpus  is  to  be 
removed,  the  section  of  this  bone  should  be  slightly  oblique,  and  the 
line  of  incision  a  partial  oval,  beginning  at  the  web  between  the  two 
fingers,  and  traveling  along  the  crease  formed  by  flexion  of  the  finger 
on  the  metacarpus  well  up  on  the  dorsum  of  this  bone,  about  three 
fourths  of  an  inch  back  of  the  joint.  An  incision,  almost  in  a  straight 
line,  should  now  be  made  between  the  ends  of  this  curved  line  (Fig.  166). 
Dissect  the  flaps  clear  and  without  making  a  disarticulation,  expose  the 
bone,  and  with  a  fine  saw  divide  it  obliquely  from  before  backward,  and 
from  the  ulnar  toward  the  radial  aspect.  In  amp^utation  of  the  middle 
or  the  ring  finger,  the  following  method  should  be  preferred : 


Fig.  169.— (After  Eamarch.) 

Middle  Finger. — Locate  the  articulation  exactly,  and  over  this  point 
make  a  transverse  incision  extending  on  either  side  to  the  middle  of  the 
depression  between  this  digit  and  the  index- and  ring-fingers  (Fig.  166). 
From  either  end  of  this  cut  carry  a  lateral  incision  directly  forward  about 


120 


A  TEXT-BOOK  ON  SURGERY. 


n 


half  way  up  the  first  phalanx,  and  connect  these  by  a  transverse  incision 
across  the  palmar  aspect  of  the  digit  (Fig.  167).  Disarticulate  and  fold 
the  palmar  end  of  the  tlap  back  upon  the  dorsal  transverse  incision  where 
it  is  stitched. 

Another  method  is  the  oval  incision,  shown  in  Figs.  169  and  170.  By 
the  first  method  the  tactile  surface  is  better  preserved.  The  head  of  the 
metacarpal  bone  should  be  left  intact  for  the  laboring  classes.  AVhen 
the  round  expansion  of  this  bone  is  removed,  the  gap  between  the  index- 
and  ring-fingers  is  not  so  wide.  The  bone  should  be  sawed  squarely 
across  a  half  inch  behind  the  articular  surface.  All  that 
has  been  said  of  this  digit  applies  with  equal  force  to  the 
ring-finger. 

Little  Finger. — The  method  recom- 
mended in  amputation  of  the  index  at 
the  metacarpal  Joint  should  be  pre- 
ferred in  removing  the  little  finger  at 
the  same  level.  The  flap  should  be  so 
shaped  that  the  cicatrix  will  fall  on  the 
dorsum  and  toward  the  ring-finger. 
When  the  metacarpal  bone  is  to  be  di- 
vided it  should  be  cut  with  a  slight  ob- 
liquity. In  this  operation  the  oval  in- 
cision shown  in  Fig.  171  shoiild  be  made. 
"Wlien  two  or  more  fingers  require 
to  be  removed  at  the  metacarpo-phalan- 
geal  joint,  each  one  may  be  amputated  by  the  methods  described  as 
especially  suited  to  it,  or  a  common  antero-posterior  flap  may  be  made. 
As  to  the  propriety  of  removing  the  ends  of  the  metacarpal  bones,  the 
same  rules  apply  as  already  given  for  the  single  amputations. 

Through  the  Metacarpus. — When  the  end  of  the  metacarpus  can  not 
be  saved,  these  bones  should  be  divided  at  any  point  three  fourths  of  an 
inch  or  more  anterior  to  the  carpo-metacarj^al  articulation.  If  the  injury 
extends  behind  this  line,  it  is  better  to  disarticulate  at  the  carpo-meta- 
carpal  junction.  In  amputation  through  the  metacarpus,  the  flap  should 
be  made  chiefly  from  the  palmar  tissues,  so  that  the  line  of  sutures  and 
the  scar  will  be  well  on  the  dorsum  of  the  hand,  and  as  much  of  the 
tactile  sense  preserved  as  is  possible. 

Carpo- Metacarpal  Disarticulation. — When  all  the  bones  of  the  meta- 
carpus require  to  be  removed,  on  account  of  a  lesion  not  involving  the 
anterior  row  of  the  carpus,  the  amputation  should  be  made  through  the 
metacarpo-carpal  line.  If  the  anterior  row  is  involved,  the  entii'e  carpus 
should  be  removed.  When  the  thumb  is  intact,  and  the  metacarpal 
bones  of  the  four  fingers  require  removal,  the  incision  as  given  by 
Esmarch  should  be  followed.  A  curved  incision  is  made  across  the  palm, 
beginning  at  the  middle  of  the  web  between  the  thumb  and  index-finger, 
and  carried  outward  to  the  idnar  side  of  the  base  of  the  fifth  metacaii^al 
bone  (Fig.  172).  The  dorsal  incision  commences  at  the  web  between  the 
thumb  and  finger,  and  is  carried  obliquely  upward  toward  the  carpus 


Fig.  170.— (After  Esmarch.) 


Fig.  171. 


AMPUTATIONS. 


121 


until  the  junction  of  the  middle  and  upper  third  of  the  metacarpal  bone 
of  the  index-finger  is  reached,  whence  it  travels  across  the  back  of  the 
hand  to  join  the  end  of  the  i:)almar  incision  (Figs.  173,  174). 


Fio.  172. 


Fig.  173. 


Fig.  174. 


Fig.  175. 


Amputation  of  the  thumb  with  disarticulation  at  the  carpo-metacarpal 
junction  .should  be  done  as  follows  :  Just  over  the  carpo-metacarpal  joint 
on  the  dorsal  aspect  of  the  hand  commence  an  incision,  and  carry  it 
directly  along  the  metacarpal  bone  until  half  way  to  the  metacarpo-pha- 
langeal  articulation,  from  which  point  it  is  made  to  travel  along  the 
groove  between  the  thumb  and  index-finger  to  the  middle  of  the  web 
between  these  two  members,  thence  on  around  the  base  of  the  thumb 
until  the  dorsal  incision  is  reached  (Fig.  175).     In  the  case  shown  in 


Fio.  17i'>. — Epithelioma  "f  thumb. 
(From  a  patient  at  Mt.  Sinai  Hospital.) 


Fig.  177. — The  same,  after  amputa- 
tion at  the  car[X>-iuelac;jpal  joint. 


Figs.  17G  and  177  this  operation  was  jierformed.  In  amputation  of  the 
little  finger,  at  the  carpo-metacarpal  joint,  a  similar  incision  is  made 
(Fig.  178). 

The  character  of  the  injury,  the  geuei'al  condition  of  the  individual, 


122 


A  TEXT-BOOK   ON   SURCJERY, 


the  vitality  of  the  parts  involved,  may  necessitate  various  modifications 
of  the  foregoing  methods.  In  the  surgery  of  the  hand,  the  rule  in  piac- 
tice  should  be  never  to  amputate  when  possible  to  avoid  it,  and  never  to 
remove  any  more  than  is  absolutely  necessary.  Fig.  179  is  that  of  an 
amputation  after  an  injury  from  the  explosion  of  a 
shot-gun,  in  which  the  thumb,  in- 
dex, and  ndddle  lingers,  and  their 
respective  metacarpal  bones,  were 
blown  oflf.  The  line  of  incision  was 
a  lateral  one,  and  the  disarticulation 
was  at  the  carpo-metacarpal  joint. 

liddlo-CarjKtl  Joint. — In  ampu- 
tation at  the  wrist  the  carpus  should 
be  removed,  even  when  all  the  bones 
of  this  group  are  not  involved.    The 
/  ,  line  of  incision  will  depend  upon 

I  the  extent  of   the  healthy  tissues 

|;         /  availalUe  for  fcM-ming  the  covering 

j.,^  j-3  to  the  stump.    The  long  palmar  and 

short  dorsal  flaps  are  preferable  on 
/J}-^  account  of  the  iiuer  tactile  sense  of 

//"  i  the  covering  thus  secui'ed.     More- 

/  /   /  over,  the  vitality  of  the  palm  is 

/  /  /  ^  so  great  that,  if  ordinary  precau- 
/  /  I  /-..h  tions  are  observed  in  its  dissection, 
I  /     \  /    /         sloughing  will  not  occur. 

./'  First  Method. — Place  the  thumb 

\  \  and  finger  of  the  left  hand  respect- 

ively upon  the  styloid  of  the  radius 
and  ulna,    and  make  an  incision  Fio.  iro. 

across  the  dorsal  surface  of  the  wrist 
which  shall  divide  everything  straight  down  to  the 
bones  and  into  the  cavity  of  the  joint.  This  incision 
reaches  half-way  do\\ai  the  lateral  aspects  of  the  wrist. 
At  the  radial  end  of  this  cut  enter  the  scalpel,  and,  in 
shaping  the  long  flap,  follow  the  center  of  the  dorsum 
of  the  metacarpal  bone  of  the  thumb  as  far  as  the  meta- 
carpo-phalangeal  articulation.  From  this  point  cut  di- 
rectly across  the  palm  to  the  ulnar  side  of  the  fifth 
metacarpal  bone,  and  back  along  this  to  join  the  dorsal 
incision.  Dissect  the  flap  closely  from  the  flexor  ten- 
dons, and  divide  all  tendons  opposite  the  wrist-joint. 
Apply  a  cloth  retractor,  and  saw  through  the  styloid  of 
Fio.  180.  the  radius  and  ulna  just  at  the  level  of  the  articular 

surface  of  the  radius,  but  not  necessai"ily  taking  a  sec- 
tion from  this  surface.  The  radial,  ulnar,  anterior,  and  posterior  carpal 
vessels  are  tied,  the  palmar  flap  is  trimmed  down  to  fit  snugly,  and  stitched 
in  proper  position.    The  drainage-tubes  come  out  on  either  side  (Fig.  180). 


AMPUTATIONS. 


123 


Second  Method. — If  the  condition  of  the  soft  tissues  is  such  that  tlie 
long  palmar  flap  can  not  be  obtained,  the  circular  incision  shown  in  Figs. 
181  and  182  may  be  practiced.  It  is  always  advisable  to  make  a  longitu- 
dinal split  in  the  cuff  along  its  ulnar  asi^ect.     Under  other  conditions,  a 


y 


,^^=1-}-?=?^ 


Fio.  le 


^ 


\ 


Fig.  182. — Showinarcuff  stitched 
and  e.\-it  of  drains  after  the 
circular  method.  (After  Es- 
march.) 


Fig.  181. 


Fig.  184. 


lateral  flap  may  be  utilized,  after  the  thii'd  method  (Figs.  183,  184),  in 
the  flap  from  the  thumb  side  ;  or  the  fourth  method  in  which  the  flap  is 
taken  from  the  ulnar  aspect  of  the  hand. 

Forearm  above  the  Wrist.— hx  amputation  through  the  forearm,  the 
rule  ah-eady  given  as  general  applies  with  equal  force  —  namely,  that 
that  operation  is  best  which  least  disturl)s  the  nutrition  of  the  flaps. 
For  this  reason,  in  all  parts  of  the  extremity,  when  the  conditions  of  the 
tissues  permit,  the  solid  flap  should  be  used. 

First  Method. — At  a  distance  beyond  the  point  at  which  it  is  deter- 
mined to  divide  the  two  bones,  sufficient  to  provide  an  ample  covering 
for  the  stump,  with  a  scalpel  or  long  knife,  as  may  best  suit  the  opera- 
tor's taste,  make  a  circular  incision  through  the  skin,  and  just  do\vn  to  the 
deep  fascia.  When  this  incision  is  completed,  and  the  skin  retracted  up- 
ward, at  the  level  of  the  proximal  edge  of  the  wound,  divide  all  the  tissues 
squarely  and  smoothly  down  to  the  bones  and  interosseous  meml)rane. 
Along  the  ulnar  bordei',  and  immediately  over  the  inner  aspect  of  this 
bone,  make  an  incision  parallel  with  the  axis  of  the  ulna.  This  incision, 
which  splits  all  the  tissues  down  to  the  bone,  will  vary  in  lengtli  with  the 
thickness  of  the  member  at  the  point  of  amputation.     With  the  dry  dis- 


124 


A  TEXT-BOOK  ON  SURGERY. 


sector  for  the  most  part,  and  the  knife-point  when  necessary,  lift  all  the 
tissues  closely  from  the  periosteum  and  interosseous  membrane.     Fold 

the  soft  parts  back  as  far  as 
the  jjoint  of  section  with  the 
saw,  apply  a  ckjth  retractor, 
and  divide  the  bones  smooth- 
ly. The  saw  should  be  en- 
tered on  the  ulna,  which  is 
the  fixed  bone,  but  the  sec- 
tion of  the  radius  should  be 
first  completed.  The  vessels 
are  next  secured,  the  sutures 
inserted,  and  the  di-ainage- 
tube  brought  out  at  the  up- 
l^er  or  proximal  end  of  the 
longitudinal  incision.  This 
method  of  amputation  will  be 
found  preferable  in  all  cases 
where  the  section  is  through 
the  lower  half  of  the  forearm. 
In  patients  of  great  muscular 
development,  or  in  whom  the 
subcutaneous  fat  is  excessive, 
the  skin-Jlap  operation  may 
be  necessitated  in  the  upper  half.  Here  the  circular  incision,  with  a  per- 
pendicular slit  along  the  ulnar  aspect  of  the  forearm,  is  the  next  in  order 
of  preference,  or  the  rectangu- 
lar or  crescentic  symmetrical 
tiaijs  may  be  made. 

The  anatomical  relations  of 
the  parts  concerned  in  amputa- 
tions through  the  forearm  are 
admirably  shown  in  Figs.  185, 
186,  187,  and  188,  which,  with 
only  slight  modifications,  I  have 
copied  from  Prof.  Braune's  mag- 
nificent work. 

When  the  line  of  amputa- 
tion is  so  close  to  the  elbow- 
joint  that  division  of  the  bones 
is  necessitated  ^nthin  an  inch  of 
the  articular  surface  of  the  head 
of  the  radius,  the  operation  to 
be  prefeiTed  is  a  disarticulation 
at  the  elbow,  with  removal  of 
the  olecranon.    When  the  bones 


Fig.  185.*— Transverse  section  tlirout'li  the  rii;lit  upper  ex- 
tremity, one  Iburtli  of  an  inch  anterior  to  the  plane  of  the 
nidio-earpal  articulation.  Looking  at  the  surface  of  the 
stump.  1,  Railial  arten'  and  veins.  2,  Ulnar  artery, 
veins,  and  nerve.  .3,  Tendons  of  deep  and  supei-ficial 
fle.xors.  4,  Tendon  of  extensor  ossis  metaearjii  and  prirai 
internodii  poUicis.  5,  Flexor  carpi  radialis.  C,  Palmaris 
longus.  7,  Fibers  of  the  flexor  brcvis  minimi  di^riti,  from 
the'annular  ligament.  8,  Flexor  carpi  ulnaris.  It,  1", 
Extensor  cai-pi^radialis  longior  et  brevier,  ami  teiidon  of 
secundi  internodii  pollicis.  11,  Extensor  communis  digi- 
torum.  12,  E.xtensor  minimi  digiti.  13,  Extensor  carpi 
radialis.  Superficial  veins  and  nerves  are  seen  in  the 
subcutaneous  tissues. 


Fig.  ISii. — Transverse  section  showing  the  relations  of  the 
ti>sues  divided  in  amputation  throu'.'h  the  lower  third 
of  the  riirht  forearm.  Lookinir  from  below  upward. 
1,  Radial  artery  and  veins.  Just  below  this,  tendon  of 
supinator  longus,  radial  nerve,  and  close  to  the  radius 
the  tendons  of  the  extensor  ossis  metacarpi  pollicis 
and  extensor  carpi  radialis  lon^or  and  brevior.  2, 
Ulnar  artery,  veins,  and  nerve.  Z,  Median  nerve. 
4,  5,  The  posterior  and  anterior  interosseous  arteries. 


*  Al!  of  these  cuts  represent  the  surface  nearest  the  patient's  hody,  i.  e.,  the  surface  over 
which  the  vessels  are  searched  fur  after  iin  amputation. 


AilPUTATIONS. 


125 


can  be  preserved  at  the  level  of  the  lower  border  of  the  bicipital  tuber- 
osity, of  the  radius,  the  joint  should  not  be  invaded. 


Fig.  187.— Transverse  section  througli  the  middle  of  tlie  right  forearm.  Looking  from  the  periplier.v  towr.rd 
the  center.  Showing  the  relations  of  the  tissues  divided  in  amputation  at  tiis  point.  1,  Kadial  artery, 
veins,  and  nerve.    2,  Ulnar  ditto.     3,  Median  nerve.    4,  Anterior  interosseous  vessels. 


Fig.  ISS.— Transverse  section  tlirouprli  the  upper  third  of  the  right  forearm.  Looking  from  the  periphery 
toward  the  center.     1,  Kadial  artery,  nmscuhir  I'rani'hes,  veins,  and  radial  nerve.     2.  Ulnar  and  mter- 

•  osseous  arteries,  veins,  and  median  nerve.  3,  Ulnar  nerve.  The  tendon  of  insertion  of  the  biceps  is 
seen  with  tlie  radius. 


12(5 


A  TEXT-BOOK  ON  SURGERY. 


Amputation  at  this  level  (Fig.  188)  should  be  made,  as  in  other  portions 
of  the  forearm,  below. 

At  ihe  ElhoiD-Joinf — First  BfefJiod. — Make  a  circular  incision  do\\Ti 
to  the  deep  fascia  from  one  to  two  inches  anterior  to  the  tip  of  the  inter- 
nal condyle  of  the  humerus,  and,  when  the  skin  has  retracted,  at  the 
level  of  the  line  of  retraction  divide  all  the  tissues  to  the  bones.  Along 
the  posterior  surface  of  the  ulna  make  an  incision  extending  as  high  as 
the  olecranon  process.  Dissect  the  soft  tissues  neatly  from  the  peri- 
osteum and  capsule  back  to  the  condyles  on  the  lateral  and  anterior 
aspects  of  the  humerus,  and  along  the  olecranon  somewhat  higher,  in 
order  to  facilitate  disarticulation  and  the  complete  removal  of  the  synovial 
bursa,  beneath  the  insertion  of  the  triceps.  When  the  disarticulation  is 
completed,  apply  a  cloth  retractor  and  saw  a  portion  of  the  articular  sur- 
face off  at  the  level  of  the  lower  j)ortion  of  the  internal  condyle.  The 
flaps  are  now  sutured,  leaving  the  drainage-tube  out  at  the  upper  limit  of 
the  incision,  over  the  olecranon. 

Second  Method. — Make  a  circular  incision  through  tlie  skin  from  one 
inch  to  one  inch  and  a  half  below  the  level  of  the  internal  condyle. 
Along  the  posterior  aspect  of  the  ulna  make  a  second  incision,  splitting 


Fio.  189.— Transverse  section  of  ri;ht  arm  ,iust  bclnw  the  elbow-joint.  Lookinfr  at  the  surface  nearest  the 
body.  1,  ijr.ichial  artery  at  tlie  point  of  ilivision  into  ulnar  and  radial.  L',  Median  basilic  vein  com- 
municating; with  brachial.  3,  The  radial  and  interosseous  divisions  of  the  musculo-spiral  nerve  and 
radial  recurrent  artery.  4,  Tendon  of  biceps.  5,  Median  nerve  and  anterior  ulnar  recurrent  artery.  6, 
Ulnar  nerve  and  posterior  ulnar  recurrent  artery. 

the  sleeve  of  skin  as  far  back  as  the  end  of  the  olecranon.  Dissect  up 
the  flap  from  the  muscles  and  deep  fascial  attachment  until  the  joint  is 
exposed  in  front,  and  the  olecranon  posteriorly.  E.xtend  the  forearm 
fully,  enter  the  articulation  between  the  head  of  the  radius  and  the 


AMPUTATIONS. 


127 


humerus,  disarticulate,  and  saw  off  the  articuhir  surface  as  in  the  pre- 
ceding operation.  The  drainage  is  from  the  liighest  point  in  the  perpen- 
dicular incision. 

Fig.  189  shows  the  anatomical  rela- 
tions near  the  line  of  section  of  the 
soft  parts  involved  in  this  amputation. 

Arm. — The  circular  skin-and-mus- 
cle  flap  is  always  preferable,  except 
in  cases  of  extraordinary  muscular 
development,  or  an  excessive  quanti- 
ty of  subcutaneous  areolar  tissue. 

First  Method. — Make  a  circular 
cut  through  the  skin  at  a  point  suf- 
ticiently  below  the  line  of  section 
through  the  humerus  to  permit  a 
suitable  covering.  Allow  the  skin 
to  retract  up  the  arm,  and  at  this 
point  divide  everything  smoothly  and 
squarely  dowTi  to  the  bone.  Render 
the  skin  and  muscles  tense,  push  the 
point  of  the  scalpel  down  to  the  bone 
on  the  outer  side  of  the  arm,  and  lay 
the  flap  open  by  an  incision  which  is 
parallel  with  the  axis  of  the  humerus, 
periosteum  up  to  the  point  where  the  saw  is  to  be  applied,  and,  after  pro- 
tecting the  soft  parts  with  a  retractor,  divide  the  bone.  The  drainage 
should  be  from  the  upj)er  extremity  of  the  perpendicular  cut,  which, 


%m^)^^ 


Fig.  ICO. — Showinff  sutures  applied  and  exit  of 
drains  in  amputation  at  the  lower  and  middle 
thirds  of  the  humerus. 


Dissect  the  tissues  closely  from  the 


Fio.  lill.— Section  throush  the  eondvloid  expansion  of  the  risrht  arm.  Looking  at  the  surface  nearest  the 
body.  1,  Brachial  aiterv  and  vein.^,  antl  the  median  basilic  vein.  *2,  ilusculo-spind  nerve  and  superior 
profunda  artery  about  the  point  of  anastomosis  with  the  radial  recurrent.  3,  Median  nerve.  4,  Biceps 
tendou.    5,  Ulnar  nerve.     6,  Triceps  tendon. 


128 


A  TEXT-BOOK  ON  SURGERY, 


Flo.  1S2. — Transverse  section  tlirougli  junctinn  of  middle  and  lower  thirds  of  riiht  arm.  Lookincr  from  lielow 
upward.  1.  Brachial  artery,  vein,  median  nerve,  and  basilic  vein.  Near  liy  tiie  ulnar  nerve  and 
inferior  protunda  artery.  2,  Musculo-siiiral  nerve,  .superior  profunda  artery,  and  sujiiuator  longus  mus- 
cle.   Cephalic  vein  to  outer  side  of  the  hiceps  muscle. 


Fio.  193. — Transverse  section  showiiig  the  relations  of  parts  divided  in  amputation  just  above  the  middle  of 
the  humerus.  Right  side.  Looking  toward  the  center.  1,  Brachial  artery.  Near  this  the  median  nerve 
and  brachial  veins.  Internal  to  it  the  ulnar  nerve  and  inferior  profunda  artery.  More  superficial, 
the  basilic  vein.  2,  Miisculo-spiral  nerve  and  superior  ]irofunda  artery.  3,  Nutrient  artery  in  the  sub- 
stance of  the  coraco-brachialiti  muscle.     4,  Cephalic  vein. 


AMPUTATIONS. 


129 


with  the  stump  properly  elevated,  will  be  the  most  dependent  portion 
of  the  wound.     An  extra  tube  may  be  inserted  at  the  end  of  the  stump. 

Second  Mdliod. — Make  a  circular  cut  down  to  the  muscles,  and  a 
longitudinal  incision  to  the  same  depth  along  the  outer  side  of  the  arai. 
Dissect  the  sleeve  of  skin  carefully  up  to  the  line  of  section  of  the 
humerus,  and  at  this  point  divide  the  muscles  and  bone.  Drainage  as  in 
the  preceding,  or  as  shown  in  Fig.  190. 

The  anatomical  relations  in  the  several  regions  of  the  arm  are  shown 
in  Figs.  191,  192,  193. 

When  the  line  of  amputation  is  so  near  the  shoulder-joint  that  section 
of  the  bone  is  requii-ed  at  a  point  not  more  than  two  inches  below  the 
under  surface  of  the  acromion  process  of  the  scapula,  the  entire  humerus 
should  be  removed  by  disarticulation. 

At  the  Shoulder- 
Joint — First  Meth- 
od.— The  patient 
should  be  placed  so 
that  the  shoulder  is 
near  the  corner  of 
the  table  and  con- 
venient to  the  oper- 
ator. After  render- 
ing the  extremity 
bloodless,  ajjply  the 
elastic  tourniquet 
around  the  axilla 
and  over  the  clavi- 
cle and  spine  of 
the  scapula.  Hold- 
ing the  arm  so  that 
the  internal  condyle 
points  directly  to 
the  i^atient's  side, 
enter  a  long,  sharp 
scalpel  directly 
down  to  the  capsule 
of  the  joint,  just  at 
the  articulation  of 
the  clavicle  with  the 
acromion  process, 
and  expose  the  head 
and  upper  part  of  the  humerus  by  a  perpendicular  incision,  which  splits 
the  deltoid  down  to  its  insertion.  At  the  lower  end  of  this  incision  make 
a  circular  cut  through  the  skin,  and,  allowing  it  to  retract,  divide  at  this 
line  the  remaining  soft  tissues  down  to  the  bone.  In  order  to  prevent 
any  bleeding,  in  case  the  tourniquet  should  not  be  sufficiently  tight,  an 
assistant  should  be  j-eady  to  grasp  the  flap  just  below  the  tourniquet,  or 
press  the  subclavian  against  the  first  rib.     The  entii-e  flap  is  now  dis- 

9 


Fig.  194. 


130 


A  TEXT-BOOK  ON  SURGERY. 


sected  up  from  the  pericjsteum  and  capsule,  and  disarticulation  accom- 
plished by  cutting  the  capsule  as  close  to  the  margin  of  the  glenoid  cavity  as 
possible  {Fig.  194).     The  vessels  are  now  secured,  ami  the  wound  sutured 

and  drained,  as  shown  in  Fig. 
195.  This  method  is  a  modili- 
cation  of  the  old  operation  of 
Larrey,*  to  which  it  is  much 
superior.  Esnuircli  has  still  fur- 
ther modified  this  amputation 
by  sawing  the  bone  immediate- 
ly after  the  circular  incision  is 
completed,  and  then  disarticu- 
lating. 

Lower  Extremity. 


Amputation  of  the  Toes. — 
The  same  methods  given  for  the 
fingers  should  be  emi:)loyed  in 
amputations  of  the  toes.  The 
long  plantar  Hap  is  always  pref- 
erable in  these  operations,  not 
so  much  for  the  jireservation  of 
the  more  perfect  tactile  sense 
Fig.  195.  of  this  surface  in  covering  the 

stump,  but  chiefly  in  order  to 
bring  the  cicatrix  on  top  and  away  from  pressure.  When  an  anii)uta- 
tion  is  necessitated  for  a  lesion  near  the  articulation  between  the  first 
and  second  phalanges  in  which  only  the  anterior  extremitj-  of  the  first 

*  iMrrey's  Method. — A  straight  incision,  dividing  all  the  tissues  down  tlirongh  the  capsule 
to  the  hone,  extending  from  the  tip  of  the  acromion  process  to  about  one  inch  below  the  articu- 
lar surface  of  the  head  of  the  humerus.  From  the  center  of  this  cut  an  incision  on  either  side 
of  the  arm,  running  obliquely  downward  and  forward,  dividing  all  the  tissues  down  to  the  peri- 
osteum, and  extending  about  two  thirds  of  the  distance  from  the  apex  of  the  shoulder  to  the 
axilla.  Elevate  the  tissues  so  as  to  fully  expose  the  joint,  press  the  arm  upward,  in  order  to 
dislocate  the  head  of  the  bone  through  the  incision  in  the  capsule,  carry  a  long,  thin  knife  across 
and  through  the  capsule,  and  complete  the  oval  flap  by  cutting  along  the  under  surface  of  the 
humerus  in  the  line  of  the  oblique  incisions  already  made.- 

Dupuytreri's  Method. — Place  the  arm  to  be  amputated  at  a  right  angle  to  the  trunk,  grasp 
and  raise  the  deltoid  with  the  left  hand,  and  transfix  the  shoulder  from  before  backward  with 
a  long  knife,  which  is  introduced  anterior  to  the  axillary  vessels,  perforates  the  capsule,  and 
emerges  on  the  posterior  aspect  of  the  arm.  A  long  (deltoid)  flap  is  now  made  by  cutting  down- 
ward, close  to  the  bone,  to  near  the  deltoid  tubercle.  While  an  assistant  holds  this  flap  up  out 
of  the  way,  the  arm  is  carried  to  the  side  of  the  body,  and  the  humerus  pressed  upward,  in 
order  to  facilitate  its  dislocation.  The  long  head  of  the  biceps,  and  the  tendons,  inserted  into 
the  tuberosities,  are  now  divided,  and,  if  necessary,  the  incision  in  the  capsule  lengthened. 
iVfter  the  luxation  is  accomplished,  insert  the  knife  as  in  the  operation  of  Larrey,  making  the 
posterior  flap  by  the  same  manoeuvre. 

[Many  other  methods  have  been  devised  for  the  performance  of  this  operation,  but  the 
method  first  given  meets  all  the  indications  so  fully  that  it  must  supersede  all  others.] 


AMPUTATIONS. 


131 


phalanx  is  involved,  section  through  the  bone  should  be  preferred  to 
disarticulation  at  the  metatarso-phalangeal  joint,  provided  that  the  line 
of  section  is  through  the  anterior  thud  of  the  phalanx.  Disarticula- 
tion of  two  or  more  consecutive  toes  at  the  metatarso-phalangeal  Joint 
may  be  effected  by  a  continuous  incision.  Amputation  of  all  the  toes  at 
this  articulation  is  performed  as  follows  :  Urasp  and  forcibly  flex  the 
toes,  and  make  an  incision,  commencing  just  posterior  to  the  inner  aspect 
of  the  metatarsal  joint  of  the  great  toe,  curving  forward  along  the  side  of 
the  first  phalanx  to  a  point  as  far  advanced  as  the  web 
between  the  toes,  and  then  across  the 
base  of  each  digit  on  this  ]>lane  until 
the  outer  side  of  the  metatarsal  bone 
of  the  fiith  toe  is  reached  at  a  point 
corresponding  to  that  at  which  the 
incision  was  begun.  With  the  toes 
now  fully  extended,  a  symmetrical 
flap  is  next  cut  along  the  plantar  as- 
pect by  an  incision  which  almost 
merges  into  the  first  line  at  the  ante- 
rior margin  of  the  web  (B^igs.  196, 197). 
Dissect  up  each  flap  as  far  back  as 
the  metatarso-phalangeal  articulation, 
leaving  the  tendons  to  be  divided  at 
this  point.  The  disarticulation  may 
be  best  effected  with  a  strong  narrow 
scalpel,  while  the  ligaments  are  made 
tense  by  forced  flexion. 
Second  MetJiod. — A  separate  amputation  may  be  made  for  each  toe. 
Throvgh  the  Metatarsus. — When  the  loss  of  tissue  requires  an  ampu- 
tation behind  the  metatarso-phalangeal  articulation,  section  of  one,  or 
even  all,  of  the  metatarsal  bones  should  be  effected  rather  than  unneces- 
sarily sacrifice  any  portion  of  the  foot  by  disarticulation  at  the  tarso- 
metatarsal joint.  The  line  of  section  should  alwaj-s  be  as  near  the  anterior 
extremity  as  possible,  and  when  it  falls  within  three  fourths  of  an  inch  from 
the  tarso-metatarsal,  joint,  a  disarticulation  should  be  made  at  this  point. 
Amputation  through  the  entire  metatarsus  should  be  made  with  a 
long  plantar  and  short  dorsal  flap,  so  that  the  scar  wUl  fall  on  the 
dorsum  of  the  foot  and  away  from  pressure.  The  dorsal  incision  should 
be  made  almost  directly  across  the  foot,  and  on  a  line  with  the  plane  of 
section  through  the  bones.  The  plantar  flap  should  begin  on  the  inner 
side  of  the  first  metatarsal  bone,  and  follow  this  forward  as  far  as  is 
necessary  to  secure  a  flap  of  sufficient  length.  It  is  always  wise  to  make 
this  a  little  too  long,  so  that  it  may  be  trimmed  down  and  made  to  fit 
nicely  as  the  sutures  are  being  adjusted.  The  incision  is  next  carried 
across  the  sole  of  the  foot  to  the  outer  surface  of  the  metatarsal  bone  of 
the  little  toe,  and  back  along  this  to  the  point  of  junction  with  the  end 
of  the  dorsal  cut.  All  of  the  tissues  should  be  divided  directly  down  to 
the  bones  in  this  incision,  and  the  flap  dissected  up,  keeping  the  knife- 


FiG.  196. 


Fio.  197. 


132  A  TEXT-BOOK  ON  SURGERY. 

point  always  in  contact  with  the  periosteum,  so  that  the  vessels  may  be 
avoided.  After  the  bones  are  sawn  through,  the  lower  flap  is  turned  into 
jiosition  and  suitably  trimmed.  The  vessels  are  next  secured,  the  sutures 
applied,  and  the  drainage-tubes  brought  out  at  each  side. 

At  file  Tarso-Metatarsal  Articulation — First  Metatarsal. — Ami)uta- 
tion  of  the  great  toe,  with  disarticulation  of  its  metatarsal  boup  at  the 
tarsal  Joint,  is  effected  as  follows  :  At  a  point  about  half  an  inch  behiiul 
the  articulation  of  the  metatarsal  bone  with  the  internal  cuneiform,  and 
immediately  between  the  dorsal  and  internal  lateral  aspects  of  tliis  bone, 
commence  an  incision  which  is  carried  forward  to  the  phalangeal  junction. 
Thence  it  is  continued  around  the  base  of  the  toe,  across  its  plantar  sur- 
face, and  back  through  the  web  between  the  first  and  second  digits,  and 
back  to  the  end  of  the  straight  incision  over  the  metatarso-phalangeal 
joint  (Fig.  198).  Dissect  the  soft  parts  closely  from  the  bone,  taking  care 
not  to  wound  the  plantar  vessels,  and  disarticulate.  The  preservation  of 
the  jwsterior  portion  of  the  first  metatarsal  bone  is  always  desirable,  on 
account  of  its  giving  insertion  to  the  peroneus-longus  and  pai-tially  to  the 
tibialis-anticus  muscle,  the  former  being  a  strong  supporter  of  the  trans- 
verse arch  of  the  foot,  and  the  latter  offering  the  chief  resistance  to  the 
sural  muscles. 

..Mi 


Fio.  198.  Fig.  190. 

Fifth  Metatarsal. — One  fourth  of  an  inch  behind  the  tubercle  of  the 
fifth  metatarsal,  and  over  the  center  of  the  dorsal  aspect  of  this  bone, 
commence  an  incision,  w^hich  is  carried  directly  forward  until  near  the 
first  phalanx,  when  an  oval  is  described  around  the  base  of  the  little  toe 
(Fig.  199).  Keep  close  to  the  bone  in  the  dissection.  The  disarticulation 
is  more  easily  effected  by  division  of  the  jieroneus  brevis  and  peroneus 
tertius,  and  by  entering  the  articulation  from  the  outer  side.  The 
importance  of  the  posterior  portion  of  this  bone  is  less  than  that  of 
the  metatarsal  bone  of  the  great  toe,  but  it  should  never  be  needlessly 
sacrificed. 

One  or  more  of  the  intervening  metatarsal  bones  may  be  removed  in 
an  amputation  of  their  respective  toes  in  practically  the  same  manner  as 
the  preceding.  The  incision  should  be  begun  far  enough  behind  the 
tarso-metatarsal  joint  to  thoroughly  expose  the  ligaments  and  facilitate 
disarticulation — not  an  easy  process  when  only  a  single  bone  is  to  be 
removed.  The  incision  should  be  made  exactly  along  the  middle  line  of 
the  dorsal  aspect. 


AMPUTATIONS. 


133 


Amputation  of  the  entire  metatarsus  should  always  be  made  through 
the  articular  plane  (Lisfranc).  The  modification  of  this  procedure  by 
Hey,  which  consisted  in  disarticulating  the  four  outer  metatarsal  bones 
and  sawing  the  end  of  the  internal  cuneiform  off  at  the  line  of  the  second 
metatarsal  bone,  is  altogether  unnecessary. 

Method — Dorsal  Incision. — Place  the  thumb  and  index  of  one  hand 
respectively  half  an  inch  behind  the  articulations  of  the  first  and  fifth 
metatarsal  bones  with  the  .cuneiform  and  cuboid,  and  at  the  most  con- 
venient one  of  these  points  commence  the  dorsal  incision,  carrying  it 
directly  forward  to  the  base  of  the 
metatarsus,  and  then  across  the  foot 
one  fourth  of  an  inch  in  front  of  the 
tarso-metatarsal  articulation,  finish- 
ing at  the  opposite  side  (Fig.  2()0). 
This  incision  should  have  a  slight 
forward  convexity,  and  should  di- 
vide all  tissues  down  to  the  bones. 
Dissect  the  flap  closely  from  the 
periosteum  to  about  one  fourth  of 
an  inch  behind  the  line  of  articula- 
tion. 

Plantar  Flap. — From  the  same 
point  as  for  the  dorsal  incision,  carry 
the  knife  directly  forward  on  the  lat- 
eral aspect  of  the  metatarsal  bone 
to  the  metatarso-phalangeal  joint, 
where  the  line  of  incision  should 
begin  to  describe  a  curve  until  the  interdigital  web  is  reached,  along 
which  it  travels  across  the  foot,  and  thence  back  along  the  opposite 
metatarsal  bone  to  the  level  of  the  tarsus  (Fig.  201). 

This  flap  should  be  lifted  by  deep  dissection,  keeping  close  to  the 
under  surface  of  the  bones,  in  order  to  interfere  as  little  as  jwssible  with 
the  vascular  sui:)ply.  An  assistant  should  now  hold  both  flaps  well 
back,  while  with  a  narrow,  short  scalpel  the  disarticulation  is  effected 
as  follows : 

Grasp  the  metatarsus  with  one  hand  and  forcibly  depress  it  until  the 
ligaments  are  put  upon  the  stretch.  Enter  the  knife  just  behind  the  tip 
of  the  fifth  metataisal  bone  and  carry  it  inward  with  a  slight  forward 
inclination,  disarticnlatiug  on  this  plane,  and  in  succession  the  fifth, 
fourth,  and  third  bones,  until  the  knife  is  arrested  by  the  outer  surface 
of  the  second  metatarsal.  The  line  of  this  articulation  is  almost  parallel 
with  that  just  followed,  but  it  is  placed  from  one  eighth  to  one  fourth  of 
an  inch  posterior  to  it,  and  may  be  readily  found  by  moving  the  meta- 
tarsal bone  upon  the  cuneiform.  The  joint  between  the  metatarsal  bone 
of  the  great  toe  and  the  internal  cuneiform  is  about  one  fourth  of  an  inch 
anterior  to  that  of  its  fellow,  being  continuous  with  the  line  of  the  three 
outer  bones.  The  flaps  should  now  be  trimmed  and  nicely  fitted,  and 
any  ragged  ends  of  tendons  clipped  off  by  the  scissors,  after  which  the 


Fifi.  200. 


Imo.  201. 


134 


A  TEXT-BOOK   ON   SURGERY. 


I'iiogoS. 


vessels  are  tied  and  the  sutures  adjusted,  leaving  the  drainage  tubes  out 
at  each  angle. 

One  point  of  precaution  is  essential,  namely,  to  avoid  division  of 
that  part  of  the  tendon  of  the  tibialis  anticus  wliich  is  inserted  into  the 
internal  cuneiform  near  its  metatarsal  articulation.  One  of  the  objections 
to  this  operation  is  the  elevation  of  the  heel,  and  the  consequent  depres- 
sion of  the  stump  by  the  action  of  the  sural  muscles,  which  action  is 

practically  unopposed  if  the  inser- 
tion of  the  tiliialis  anticus  is  divided. 
Should  this  occur,  or  shoidd  the 
heel  be  too  greatly  elevated,  the 
tendo  Achillis  should  be  divided  as 
in  talipes  equinus.  The  line  of  sec- 
tion through  the  internal  cuneiform 
bone  is  shown  in  Fig.  202.  This — 
the  operation  of  Hey — is  objection- 
able for  two  reasons.  In  the  tirst 
l)lace,  it  cuts  away  a  part  of  the 
bony  framework  of  the  foot,  which 
need  not  be  sacrificed  ;  and,  sec- 
ondly, it  completely  severs  the  at- 
tachment of  the  tibialis  -  anticus 
muscle. 

Through  the  Tarsus. — When  re- 
moval of  any  part  of  the  anterior  row 
of  tarsal  bones  is  required,  the  fol- 
lowing rules  should  be  adoj^ted :  If 
the  internal  cuneiform  is  involved 
only  on  its  anterior  articular  surface, 
it  may  be  sawn  through  on  the  line 
of  Iley  (Fig.  202).  If  a  section  pos- 
terior to  this  plane  is  necessarj',  dis- 
articulation at  the  scaphoid  should 
be  done.  If  the  middle  or  external 
cuneiform  is  involved  only  to  a 
limited  extent  upon  its  anterior  por- 
tion, as  much  as  one  fourth  of  an 
inch  of  this  surface  may  be  sawn  or 
scraped  off.  Behind  this  limit  a 
disarticulation  from  the  scaphoid 
should  be  made.  Through  the  culioid  the  line  of  section  may  pass 
at  any  point  anterior  to  the  middle  of  this  bone — the  line  of  Forbes 
(Fig.  202). 

Forbes\s  Method. — Disarticulatitm  f)f  the  three  cuneifonn  bones  from 
the  scaphoid,  and  section  of  the  cuboid  parallel  with  the  plane  of  the 
anterior  surface  of  the  scaphoid  (Fig.  202).  The  dorsal  and  plantar  in- 
cisions are  slightly  anterior  to  and  practically  the  same  as  in  Chopart's 
amputation.     The  dissection  should  be  made  closely  from  the  bones,  and 


Metatarsus 

in 
continuity. 


I  Phalanges 
in 
continuity. 


Fig.  202. 


AMPUTATIONS.  135 

the  flaps  trimmed  and  adjusted  as  in  the  preceding  operation.  Section 
of  tendo  A  chillis  may  be  done  later,  if  necessary. 

3Iedto-Tar-sal — Operation  of  Chopart. — The  dorsal  incision  is  begnn  on 
a  level  with  and  an  inch  posterior  to  the  tip  of  the  base  of  the  tifth  meta- 
tarsal bone  (for  the  adult  foot).  This  point  is  about  one  fourth  of  an  inch 
behind  the  articulation  between  the  cuboid  and  calcaneum  (Figs.  199,  203). 
With  a  slight  forward  convexity  the 
incision  is  carried  across  the  top  of 
the  foot  to  the  posterior  margin  of 
the  tuberosity  of  the  scaphoid,  and 
then  directly  back  from  one  fourth 
to  half  an  inch  (Fig.  198).  The  skin, 
tendons,  vessels,  and  nerves  are  di- 
vided on  this  line,  and  the  flap  lift- 
ed until  the  joints  between  the 
astragalus  and  scaphoid  and  the 
calcaneum  and  cuboid  are  well  ex-  Fio.  203. 

posed.     From  the'ends  of  this  first 

incision  a  long  plantar  flap  is  fashioned  by  cutting  forwai'd,  as  in  shaping 
the  flap  for  the  operation  of  Lisfranc  (Figs.  198,  199).  Disarticulation  is 
effected  with  a  short,  strong  scalpel,  while  forcible  extension  is  employed. 
The  flaps  are  now  to  be  properly  trimmed,  and  the  vessels  secured. 
Division  of  the  tendo  Achillis  may  be  done  later.  AVhen  required,  this 
operation  may  be  modified  by  sawing  off  the  anterior  half-inch  of  the 
astragalus  and  calcaneum.     The  incisions  are  practically  the  same. 

Calcaneo-Astragaloid  Disarticulation. — This  operation  was  first  sug- 
gested by  LigneroUes,  first  perfonned  by  Textor,  but  brought  into  promi- 
nence by  Malgaigne.  When  in  an  ampiitation  of  the  foot  at  the  medio- 
tarsal  joint  it  is  discovered  that  the  as  catcis  must  also  be  removed,  and 
if  the  astragalus  is  sound,  the  subastragaloid  operation  should  be  pre- 
feiTed  to  the  amputation  of  Syme  at  the  tibio-tarsal  joint.  By  this 
method  a  shortening  of  about  two  inches  is  prevented,  and,  although  the 
under  surface  of  tlie  astragalus  is  uneven,  experience  has  shoA\Ti  that  the 
pressure  is  safely  distributed,  and  a  useful  stump  results.  Moreover,  the 
degree  of  mobility  maintained  at  the  tibio-astragaloid  articulation  adds 
to  the  ease  and  comfort  of  locomotion. 

Seize  the  foot  with  the  left  hand,  and  with  a  strong  scalpel  commence 
the  incision  by  dividing  the  skin  and  tendo  Achillis  just  at  the  level  of  the 
upper  surface  of  the  os  calcis.  From  this  point  the  incision  is  continued 
along  the  fibular  side  of  the  foot  forward,  dividing  everything  down  to  the 
bone,  and  curving  slightly  downward  until,  as  it  passes  below  the  tip  of  the 
external  malleolus,  it  is  four  tenths  of  an  inch  below  this  point  (Fig.  204). 
The  line  of  incision  is  now  carried  du-ectly  forward  until  near  the  tuber- 
osity at  the  base  of  the  fifth  metatarsal  bone,  where  it  curves  to  the  dor- 
sum of  the  foot,  crossing  to  the  inner  side  over  the  anterior  edge  of  the 
scaphoid,  and  then  straight  down  and  under  the  foot  a  half-inch  beyond 
the  middle  of  the  sole  (Figs.  205,  206).  From  this  jjoint  a  straight  incision 
is  made  directly  back  to  the  point  of  beginning  at  the  inner  edge  of 


136 


A  TEXT-BOOK   OX   SURGERY. 


the  tendo  Achillis  (Fig.  206).     Lift  the  plantar  flap  by  deep  and  careful 
dissection  from  the  bone,  leaving  nothing  but  the  periosteum,  until  the 


Fig.  204.— (.\fter  Malgaigne.) 


Fio.  205.— (After  Malj^-aigne.) 


Fig.   206.^(After   Mal- 
gaigne.) 


calcaneo-astragaloid  articulation  is  well  exposed.  The 
flaps  being  held  by  an  assistant,  the  disarticulation  is 
begun  by  opening  the  asti-agalo-scaphoid  joint  and 
removing  the  anterior  pait  of  the  foot  at  the  medio- 
tarsal  joint.  The  os  calcis  should  now  be  seized  with 
a  lion-tooth  forceps,  and  the  disarticulation  of  this 
bone  effected.  The  exposed  tendons  should  be  smooth- 
ly divided  with  the  scissors  at  the  higher  portions  of 
the  incision.  After  deligation  of  the  vessels  the  flap 
is  properly  trimmed  and  sutured,  the  cicatrix  falling 
upon  the  dorsal  and  external  lateral  aspects  of  the 
stump.* 

*  Hancock's  modification  of  this  pro,-edure,  or  the  su'oastragaloid- 
osteoplastic  amputation,  is  as  follows:  One  incision  begins  beneath 
and  at  the  posterior  angle  of  the  outer  malleolus,  and  is  carried  along 
the  outer  surface  of  the  foot  to  a  point  a  half-inch  anterior  to  the  pro- 
jecting base  of  the  fifth  metatarsal  bone.  A  second  incision  is  made 
along  the  inner  border  of  the  foot,  commencing  posteriorly  about  the  center  of  the  internal 
malleolus  anil  terminating  anteriorly  at  a  spot  opposite  the  end  of  the  external  incision.  The 
anterior  ends  of  both  cuts  are  joined  by  a  curved  in- 
cision made  with  its  convexity  forward  across  the 
plantar  aspect  of  the  foot,  and  dividing  all  the  tis- 
sues well  down  to  the  bone.  Reflect  this  flap  back 
as  far  as  the  projections  at  the  under  surface  and  in 
front  of  the  tuberosity  of  the  os  calcis,  and  make  a 
fourth  incision  across  the  dorsum  of  the  foot  imme- 
diately behind  the  head  of  the  astragalus.  Apply  the 
saw  upon  the  under  surface  of  the  calcaneum  a  little 
anterior  to  its  center,  and  cut  through  the  bone  ob- 
liquely from  below  upward  and  t)ackward  (Tig.  207). 
With  the  knil'e  enter  the  mediotarsal  joint,  pass  the 
instrument  under  the  hejid  of  the  astragalus,  and,  cat- 
ting from  before  backward,  sever  the  interosseous  ligament  and  detach  the  anterior  part  of  the 
foot,  together  with  the  segment  of  the  os  calcis.  Saw  otf  tlie  head  of  the  astragalus,  and  with 
a  sharp  bone-cutter  (or  saw)  remove  the  two  articular  cartilages  (and  a  thin  slice  of  bone)  from 
the  under  surface  of  the  astragalus.  As  the  flaps  are  adjusted,  the  sawn  surface  of  the  calca- 
neum is  brought  into  apposition  with  the  under  surface  of  the  astragiilus.  See  "Lancet,'^ 
September,  1866,  p.  257. 


Fig.  207. — Section  of  os  calm  mid  astragalus 
in  Ilancocli  s  operation. 


AMPUTATIONS. 


137 


Amputation  of  the  Foot — Tiblo-Tarsal  {Syme's). — When  the  astraga- 
lus must  be  removed,  together  with  the  foot,  the  amputation  of  Syme, 
which  involves  a  disarticulation  of  the  tibio-astragaloid  joint,  and  a  sub- 
sequent section  of  the  articular  surfaces  of  the  tibia  and  fibula,  should 
be  made.  In  its  successful  performance  certain  precautions  are  neces- 
sary, chief  among  which  is  the  preservation  of  the  proper  vascular  sup- 
ply to  the  posterior  flap.  The  failure  to  appreciate  the  importance  of 
making  the  plantar  incision  far  enough  forward,  as  laid  down  by  Syme, 
has  brought  this  procedure  somewhat  into  disrepute,  for  Prof.  Stephen 
Smith,  in  his  comprehensive  report,  says  the  necessity  for  re-amputation 
is  3  per  cent  greater  in  this  than  in  any  other  amputation. 

In  my  "Prize 
Essay,"  published 
in  1876,*  I  demon- 
strated that  the  ar- 
terial distribution 
to  the  calcaneo- 
plantar  flap  was 
chiefly  derived 
from  the  external 
plantar  artery,  and 
from  the  posterior 
tibial  so  near  the 
bifurcation  of  this 
vessel  into  its  ter- 
minal branches, 
that  any  line  of  in- 
cision in  the  forma- 
tion of  this  flap 
which  necessitated 
the  application  of 
a  ligature  at  or  very 
near  its  bifurcation 
was  not  justifiable. 
I  do  not  doubt  that 

the  sloughing  so  often  met  with  at  this  point  is  caused  by  carrying  this 
incision  too  far  back  toward  the  tuberosity  of  the  calcaneum.  The  arte- 
rial supply  is  shown  in  Fig.  208,  from  my  "Essays  in  Surgical  Anatomy 
and  Surgery."  f 

Modified  Procedure. — With  the  foot  held  at  an  angle  of  90°  to  the 
axis  of  the  leg,  place  the  thumb  at  the  tip  of  one  malleolus,  and  the 
index  at  the  other,  and  from  the  center  of  the  maUeohis  intenius  carry  an 
incision  directly  across  the  sole  of  the  foot  to  a  point  one  fourth  of  an 
inch  anterior  to  the  tip  of  the  malleolus  extemns.  This  incision  should 
divide  all  the  tissues  to  the  bones,  and.  as  wiU  be  seen  in  Figs.  209  and 
210.  its  perpendicular  portion  descends  in  a  direction  slightly  anterior  to 


Fig.  208.— pia^T.im  showing  the  arterial  supply  to  the  calcanean  reirfon,  on 
the  tibial  side  of  the  foot.  (Drawn  by  tne  author,  from  the  average  of 
eighty-seven  dissections.)  m,  Internal  malleolus,  pmcu,  Tibio-tarsal 
quadrilateral,  tlie  surgical  region  of  this  articulation,  k.  Posterior  tibial 
artery,  o,  Its  point  of  bifurcation  into  g,  Internal  plantar,  and  /",  Ex- 
tenml  plantar  artery.  Hi,  Calcanean  branches  of  external  plantar,  t, 
Articular  branches  from  posterior  tibial.  A,  Articular  braneu  from  in- 
ternal plantar,  j,  Tendon  of  tibialis  posticus  muscle,  r.  Tendon  of 
fle.xor  longus  digitorum.  «,  Tendon  of  flexor  longus  poUieis.  m  c,  The 
line  of  incision  of  Gro:*s.  vi  /,  m  </,  m  e,  m  <=,  Lines  oi  incision  sliowing 
that  the  nearer  the  incision  approaches  the  heel,  the  more  danger  is  in- 
curred of  cutting  off  the  principal  blood-supply  to  the  calcanean  flap,  in 
amputation,  m  re,  Line  crossing  the  usual  point  of  bifiircatioD  ot  the 
posterior  tibial.    ma,mb,  Anterior  incision. 


»  "  American  Journal  of  tlie  Medical  Sciences,"  April,  187G.  t  William  "VTootl  &  Co.,  1879. 


138 


A  TEXT-BOOK  ON  SURGERY. 


the  axis  of  the  tibia.  The  ends  of  this  rut  are  uuited  by  a  second,  which 
arches  sharply  upward  about  on  the  line  of  section  of  the  bones,  and 
should  also  divide  tendons  and  all  interveninu'  structures,  opening  into 
the  joint.     The  foot  should  now  be  linnly  grasped  and  extended,  so  as 


Fig.  203. 


Fio.  210. 


to  make  tense  the  anterior  ligament  of  the  ankle,  which  is  easily  divided. 
Carrying  the  knife  to  either  side  of  the  articular  surfaces  of  the  astra- 
galus, the  lateral  ligaments  are  cut,  and  the  joint  thus  widely  exposed. 
An  assistant  now  holds  and  depresses  the  foot,  while  the  operator  care- 
fully dissects  the  tissues  closely  from  the  astragalus  and  calcaneum. 
Care  should  be  taken  not  to  bruise  the  flap  by  too  great  traction.     In 
dis.secting  along  the  inner  surface  of  the  ankle,  the  knife  should  lie  kept 
close  to  the  bones,  so  that  when  the  lesser  process  of  the  calcaneum  is 
reached  it  will  slide  behind  and  under  this  process,  passing  between  it 
and  the  flexor  tendon  and  the  vessels.     If  this  precaiition  is  not  taken, 
the  arteries  may  be  wounded  and  the  nutrition  of  the  flajo  seriously  im- 
paired.     As  the  dissection  proceeds, 
L  I      ,         the  foot  is  further  depressed,  and  the 
ft      \        tendo  Achillis  separated  from  its  in- 
f-f  '      ^      sertion  into  the  tuberosity  of  the  cal- 
caneum, in  doing  wdiich  care  must  be 
taken  not  to  button-hole  the  flap.    The 
posterior  portion  of  the  os  calcis  may 
now  be  brought  through  the  joint,  and 
the  dissection  continued  in  this  direc- 
tion or  finished  by  working  back  along 
the  under  surface  of  this  bone.     After 
the  foot  is  removed,  the  flaps  are  lifted 
from  the  tibia  and  fibula  until  a  sec- 
tion of  these  bones  can  be  made  just 
on  the  level  of  the  anterior  articular 
margin  of  the  tibia  (Fig.  211).     It  is 
not  necessary  to  remove  the  artic^^lar 
surface.      The    flaps   should    now   be 
trimmed  and  fitted,  and  the  vessels  tied.     As  the  sutiires  are  applied,  it 
will  be  noticed  that  there  is  a  redundancy  of  tissue  in  the  long  flap,  leav- 
ing a  cup-shaped  cavity ;  but  this  can  be  thoroughly  drained  from  the 
angles  of  the  wound,  and  disappears  when  the  stump  is  healed  (Fig.  212). 


Fio.  211. 


-iituinp  after 
Syme's  amputation. 
(After  Mulgaignc. ) 


AMPUTATIONS. 


139 


Syme's  amputation  at  the  ankle  has  been  modified  by  the  osteoplastic 
operations  of  Pirogoff,  Le  Fort,  Guntlier,  and  others. 

Pirogoff^s  3Iet?iod. — The  dorsal  and  plantar  incisions  are  made  from 
the  same  points,  and  are  practically  the  same  as  in  Syme's  amputation. 
However,  in  order  to  avoid  redundancy  of  the  soft  tissues  and  to  expose 
the  calcaneum  back  to  the  line  of  section  of  this  bone,  the  lower  incision 
should,  when  it  reaches 
the  sole  of  the  foot, 
be  carried  back  about 
three  fourths  of  an  inch 
nearer  the  heel  than  in 
Syme's  method.  The 
dorsal  incision  does  not 
ascend  so  high  upon 
the  ankle  by  the  same 
distance.  The  joint  is 
opened  through  the  an- 
terior incision,  and  the 
lateral  ligaments  di- 
vided until  the  ante- 
rior upper  surface  of 
the  OS  calcis  can  be  dis- 
placed forward  through 
the  articulation,  when 
it  is  sawn  through  on 
the  line  indicated  in  Fig.  214,  the  instrument  running  parallel  with  the 
edges  of  the  incision.  The  soft  parts  are  now  carefully  lifted  from  the 
articular  ends  of  the  tibia  and  fibula,  and  these 
bones  divided  horizontally  so  that  all  the  articu-         t    "  1 

lar  cartilage  is  removed  by  the  section.  The  an- 
gle described  by  these  two  lines  of  section  is 
about  90°  (Fig.  214).  The  flaps  are  adjusted  so 
that  the  i^lane  of  the  calcaneum  is  brought  snugly 


Fig.  213.— (After  Esmarch.) 


Fio.  214.— (After  Esmarch. ^ 


Fio.  215. — Stump  after  Pirogoff's 
amputation.  (After Malgaiguc.) 


in  apposition  with  that  of  the  tibia  and  fibula.     The  drainage  should  be 
fi'om  the  dependent  angles  of  the  wound  (Fig.  215). 

Le  Fort's  3Iet/iod.— Three  fourths  of  an  inch  below  the  external 


140 


A  TEXT-BOOK  ON  SURGERY. 


nialloolns  commence  an  incision  whicli  is  carried  directly  forward  t(j 
within  half  an  inch  of  the  calcaneo-cuboid  articulation.  From  this  point 
it  describes  a  curve  with  an  anterior  convexity  over  the  dorsum  of  the 
foot,  following  the  line  of  the  astragalo-scaphoid  joint  until  the  inner 
border  of  the  foot  is  reached  (Fig.  216),  when  it  is 
carried  back  and  ended  at  a  point  about  one 
inch  in  front  of  the  tip  of  the  intei'nal  mal- 
leolus, which  point  is  directly  between  the  tuber- 
osity of  the  scaphoid  and  the  tip  of   the  mal- 


16.— (Allcr  Le  Fort.) 


Fio.  '217.— (.VlterLe  Fort.) 


leolus.  From  the  anterior  limit  of  the  straight  incision  l)elow  the  ex- 
ternal malleolus  describe  a  i^lantar  tiap  also  with  a  forward  convexity 
across  the  sole  of  the  foot,  as  shown  in  Fig.  217.  Dissect  up  the  dor- 
sal flap,  in  order  to  expose  the  tibio-tarsal  joint,  taking  great  care  in 
lifting  the  inner  angle  not  to 
wound  the  tibial  and  plantar 
arteries.    The  disarticulation  of 


Via.  21!i.—i  After  Le  Fort,  i 


Fig.  213.— (After  Le  Fort.) 

the  astragalus  from  the  calca- 
neum  is  next  effected  by  intro- 
ducing a  thin  knife  from  the 
fibular  side  between  these  bones, 

and  dividing  the  interosseous  ligament.  Then  remove  the  front  of  the 
foot  at  the  medio-tarsal  joint,  and  complete  the  disarticulation  of  the 
astragalus,  and  with  the  saw  remove  the  upper  segment  of  the  calcaneum 
on  the  level  of  its  articular  surface  (Figs.  218,  219).     The  tibia  and  fibula 


AMPUTATIONS. 


141 


are  now  horizontally  divided  just  at  the  level  of  the  articular  plane  of  the 
tibia,  as  in  Syme's  operation  (Fig.  212).  In  adjusting  the  flaps,  the  sawn 
surface  of  the  calcaneum  is  brought  into  apposition  with  that  of  the  tibia 

(Fig.  220).  Or,  having  exposed  the  tibio-tarsal 
joint,  divide  the  ligaments,  disarticulate,  as  in 
SjTue's  operation,  and,  having  drawn  the  astra- 
galus and  calcaneum  forward  until  the  upper 


.^r^. 


Fig.  221. 


Fig.  2211. — stump  aiier  Le  tort's 
amputation.    (Le  Fort.) 


l^ortion  of  the  os  calcis  is  exposed,  insert  a 
key-hole  saw  behind  the  tuberosity,  and  saw 
through  this  l)one  on  the  line  already  indicated. 
Gunther's  modification  of  this  procedure  is  shown  in  Figs.  221,  222, 
223,  224,  225,  taken  from  Esmarch's  hand-book,  and  the  crescentic  section 


Fig.  224. 

of  the  bones,  as  practiced  by  P. 
Fig.  225.  Bruus,  is  secu  in  Fig.  226,  from 

the  same  source. 
In  amputations  of  the  foot  the  following  rules  should  be  obsen'ed : 
The  terminal  phalanges  of  all  the  toes  should  be  removed  by  disarticula- 
tion when  it  becomes  necessary  to  remove  a  portion  of  the  entire  thickness 
of  these  bones.     The  same  rule  applies  to  all  the  second  phalanges,  ex- 


142  A  TEXT-BOOK   ON  SURGERY. 

cept  that  of  the  great  toe,  which  should  be  sawn  through  at  any  point 
anterior  to  its  middle.  If  a  section  posterior  to  this  is  required,  disar- 
ticulate from  the  metatarsal  bone.     AV'hat  has  been  said  of  the  second 

l)lialanx  of  the  great  toe  applies  with 
equal  force  to  the  proximal  phalanges 
of  all  the  other  toes. 

None  of  the  metatarsal  bones  should 
be  disarticulated  from  the  tarsus  vvlien 
a  section  is  possilile  from  not  less  tlian 
three  fourtlis  of  an  inch  anterior  to  each 
tarso-metatarsal  joint. 

When   a   section   posterior   to  this 
line  is  required,  a  tarso-metatarsal  dis- 
Fio.  226.       ^"^  articulation  should  be  effected.      Bey's 

operation  is  only  justitialile  when  the 
anterior  face  of  the  internal  cuneiform  is  diseased.  As  much  as  the  an- 
tei'ior  fourth  of  each  cuneifonn  bone,  and  the  anterior  half  of  the  cuboid, 
may  be  sa-wn  oflf,  in  preference  to  the  unnecessary  sacrifice  of  the  bony 
frame-work,  by  P"'orbes's  or  Chopart's  operation. 

When  the  cuneifonn  bones  must  be  removed,  and  the  posterior  h:ill' 
of  the  cuboid  is  sound,  Forbes's  operation  should  be  preferred  to  Cho- 
part's. Chopart's  procedure  is  next  in  order.  The  sub-astragah)id 
operation  should  always  be  preferred  to  a  tibio-tarsal  (Syme's)  amputa- 
tion. If  the  condition  of  the  parts  is  such  that  the  vitality  of  the  Hap  is 
assured,  the  operations  of  Le  Fort  and  Pirogoff,  carefully  and  skillfully 
done,  should  be  preferred  to  the  tibio-tarsal  disarticulation. 

Even  at  the  risk  of  a  second  operation  being  required,  an  effort  to 
preserve  the  gi^eatest  possible  portion  of  the  foot  is  justifiable,  except 
when  it  may  serioiisly  threaten  the  life  of  the  patient.  The  value  of  a 
surface  accustomed  to  pressure  can  only  be  thoroughly  ajjpreciated  in 
the  after-adjustment  of  an  artificial  ajjparatus. 

Lecf. — Amputation  at  any  portion  of  the  leg  above  the  line  of  section, 
in  Syme's  operation,  should  be  made  by  one  of  two  methods. 

1.  Modified  Circular  Skin-Flap. — At  a  sufficient  distance  beyond  the 
point  at  which  the  bones  are  to  be  divided  make  a  circular  cut  through 
to  the  deep  fascia,  split  the  flap  directly  over  the  fibula,  up  to  the  point 
of  section  through  the  bones,  and  carefully  dissect  up  the  cuff.  ^Vhen 
the  flap  is  reflected,  at  the  level  of  its  base  divide  all  the  soft  tissues 
squarely  down  to  the  bones,  which  are  next  sawn  through.  The  spine  of 
the  tibia  should  be  trimmed  down,  to  prevent  too  acute  pressure  and 
sloughing  of  the  skin  at  this  point,  a  not  infrequent  occurrence  when  this 
precaution  is  omitted.  The  drainage  is  at  the  fibular  side,  and,  as  the 
leg  should  be  elevated,  the  tube  should  come  out  at  the  highest  poini;  of 
the  perpendicular  incision.  When  the  bones  are  sawn  through  within 
six  inches  of  the  knee-joint,  the  remainder  of  the  fibula  should  be 
exsected. 

2.  MetTiod  of  Prof.  Stephen  SmitJ). — Commence  an  incision  in  the 
center  of  the  anterior  surface,  and  carry  it  downward  along  the  side  of 


AMPUTATIONS. 


143 


the  leg,  so  as  to  make  a  slightly  curved  flap,  with  its  convexity  below  ; 
when  the  incision  passes  over  the  prominent  part  of  the  leg  toward  the 
posterior  surface,  incline  it  upward  until  the  middle  of  the  limb  is 
reached,  wliere  it  should  be  continued  directly  up  to  the  point  at  which 
the  bone  is  to  be  divided  ;  make  a  similar  incision  on  the  opposite  side 
(Fig.  227) ;  the  flaps,  consisting  of  the  skin  and  fascia,  are  dissected  up- 


Fii.    2.7  —(After  Stej  1  lii  s,,  tl    ) 


ward  about  an  inch,  at  which  point  the  muscles  are  divided  squarely 
down  to  the  bones.  After  the  bones  are  divided,  the  hood  is  brought 
over  the  stump  and  sutured,  leaving  the  drainage  at  the  upper  part  of 
the  posterior  incision. 

In  very  emaciated  subjects,  to  forestall  the  liability  of  sloughing  in  the 
flaps,  the  first  circular  cut  should  go  directly  through  all  the  tissues  down 
to  the  bones,  and  the  perpendicular  incision  along  the  fibula  also  down 
to  this  bone.  All  the  tissues  should  then  be  lifted  closely  from  the  peri- 
osteum and  interosseous  membrane,  forming  a  solid  flap,  reflected  up  to 
the  point  at  which  the  bones  are  to  be  divided. 

When  the  line  of  amputation  approaches  nearer  than  three  inches 
from  the  upper  articular  surface  of  the  tibia,  a  complete  disarticulation 
at  the  knee  should  be  performed.  At  or  below  this  point  the  upper  por- 
tion of  the  bone  should  be  preserved,  and  the  fibula  exsected.  After 
recovery  from  the  operation  it  will  be  found  that  the  tibia  is  flexed  upon 
the  femur,  so  that,  in  the  adjustment  of  an  artificial  limb,  the  chief 
l)ressure  may  be  comfortably  borne  upon  the  normal  tissues  in  front  of 
the  patella  and  the  tuberosity  of  the  tibia.  The  greater  pressure  in  any 
prothetic  apparatus  used  after  amputation,  at  or  above  the  knee,  falls 
upon  the  ischio-perineal  region.* 

*  The  oilier  operations,  which  consisted  in 
making  a  long  and  a  short  flap  on  opposite 
sides  of  the  leg,  are  now  fallen  into  general 
disuse.  The  requirements  will  be  better  ful- 
filled by  any  one  of  the  methods  already  de- 
.scribod  than  by  the  more  comjjlicated  metli- 
ods  of  Teale,  Lee,  Sodillot,  and  others. 

Method  of  Tcalc — Lomj  (did  S/iort  Rec- 
tangular Flaps. — The  long  flap,  folding  over 
the  end  of  the  bone,  is  formed  of  parts  gen- 
erally devoid  of  largo  blood-vessels  and  nerves, 

which  structures  are  left  in  the  short  flap.  '    * '    ^'°-  22S.-(trom  Bryant.) 

The  size  of  the  long  flap  is  determined  by  tlje 
circumference  of  the  limb  at  the  place  of  amputation,  its  length  and  breadth  being  each  equal 


144 


A  TEXT-BOOK   ON  SURGERY. 


Knee-joint — First  Method — Modified  Circular  Skin-Flap. — About 
three  inches  behiw  the  patella  make  a  circular  sweep  around  the  le<r, 
dividing  the  skin  and  fascia.  Join  this  by  a  jjerpendicular  incision  iu 
the  middle  line  of  the  posterior  aspect  of  the  limb,  extending  through 
the  skin  and  fascia,  and  at  least  as  high  as  to  the  level  of  the  top  of  the 
l)atella.  Dissect  the  skin  back  carefully,  keejiing  close  to  the  anterior 
surface  of  the  patella,  as  the  skin  over  this  bone  is  usually  very  thin. 
It  is  not  necessary  to  dissect  the  culf  as  high  on  the  lateral  and  posterior 
aspects  as  in  front,  since  the  anterior  incision  is  made  to  allow  of  the 
removal  of  the  patella  and  dissection  of  the  synovial  sac  just  above  it. 
Divide  the  tendon  of  the  quadriceps  at  the  upper  limit  of  the  patella, 
turn  this  do^vn,  ciit  the  lateral  ligaments  and  capsule  along  the  edges  of 
the  condyles  of  the  femur,  Hex  the  leg  strongly  on  the  thigh,  divide  the 
crucial  ligaments,  and,  as  soon  as  the  posterior  ligament  of  Winslow  is 
exposed,  introduce  a  hmg  knife  and  remove  the  leg  by  cutting  squarely 
through  the  soft  tissues  at  the  back  of  the  articulation  (Fig.  280). 
AVith  the  cutting-forceps  round  off  the  sharp  edges  of  bone  which  mark 
the  line  between  the  articular  and  non-articular  surfaces  of  the  condyles, 
make  a  thorough  remov;il  of  the  synovial  sac  above  the  patella,  wi2)e  off 
the  articular  surface  with  a  sponge  dipped  in  1  to  3000  sublimate  solu- 
tion, tie  the  vessels,  and  close  the  flap  as  in  Fig.  236.     There  is  really 

to  half  tliG  circumference  of  tlio  limb  at  this  point.     The  short  flap  is  one  fourth  11s  long  aa 
the  other.     The  incisions  and  stump,  after  Teale's  nietliod,  are  shown  in  Fig.  228. 

Sedillofs  Method— Long  Fibular,  Short  Tibial,  Flap. — Opposite  the  point  at  wliicli  tlje 
bones  are  to  be  divided  insert  a  long,  tliin,  aniput.iting-lvnife,  tlic  i)oint  of  wliicli  sliall  graze 
tlie  spine  of  the  tibia  and  the  outer  surface  of  the  fibula,  and   come  out  through  the  outer 


aspect  of  the  calf.     Cut  downward  close  to  the  bones,  and  make  a  long,  rounded  flap.     The 
short  flap  is  made  by  an  incision  with  a  sliglil  downward  convexity  (Fig.  22'.i). 


230.— (Ashhurst's  "  Kncyclnpipdia.") 


Lee^a  Method.— The  length  of  the  flaps  is  determined  as  in  Teale's  amputation.  The  long 
flap  is  posterior,  and  includes  the  skin  and  sural  muscles.  The  deep  muscles  and  the  vessels 
are  divided  squarely  at  the  base  of  the  flap  (Fig.  2^0). 


AMPUTATIONS. 


145 


Kio.  231.— Transverse  section  of  the  rifrlit  leg  Ju^t  above  the  anklc-ioint,  showing  the  relation  of  the  parts  on 
the  plane  of  section  tbroufih  the  malleoli  in  Syme's,  Pirog'off's,  Le  Fort's,  Gimther's,  and  Bruns's 
amimtations.  Lookinjr  at  the  surface  nearest  the  body.  1,  Extensor  longus  digitorum.  2,  Anterior 
tibial  vessels  and  nerve.  .3,  Extensor  proprius  pollicis.  4,  Tibialis  anticus.  5,  Internal  saphena 
vein.  6,  Tibialis  posticus.  7,  Flexor  longus  digitorum.  8,  Posterior  tibial  artery,  veins,  and  nerve. 
9,  Flexor  longus  pollicis.  10,  Tendo  Achillis.  11,  External  cutaneous  nerve.  12,  Peroneus  brevis. 
13,  Peroneus  longus. 


Kia.  232. — Section  through  lower  third  of  risht  leg.    Looking  toward  the  center.     1,  .Anterior  tibial  ncn-v*, 
artery,  and  vcius.     2,  Posterior  tibial  artery,  vein.s,  and  nerve.     3,  I'croncal  artery  and  veins. 
10 


146 


A   TEXT-BOOK   ON   SURGERY. 


no  need  of  sawing  off  the  end  of  the  condyles.  Such  a  section  ex- 
poses a  broad  surface  of  cancellous  tissue  to  the  danger  of  absorption  of 
septic  matter,  shoidd  infhiinniation  occur.  The  skin  which  forms  the 
anterior  ixn'tion  of  the  sleeve  wliicli  falls  over  the  end  of  tlie  hone  is  less 
apt  to  suffer  from  pressure  and  slough,  as  it  rests  on  the  smnotli  rounded 
surface  of  the  articular  ex])ansi()n  of  the  femur,  than  when  after  a  sec- 
tion of  this  bone  it  rests  upon  the  sharp  edge  which  is  necessarily  left 
when  the  saw  is  employed.     The  presence  of  the  cicatrix  at  the  end  of 


Fig.  233. — Section  throuL'h  the  middle  of  the  rii^ht  leg.  Lookine  from  below  upward.  1,  .\nterior  tiWa! 
artery,  veins,  and  nerve.  2,  Posterior  tibial  artery,  veins,  and  nerve.  3.  Peroneal  artery  and  veins. 
4,  Long  saphena  vein  and  nerve.     5,  Musculo-cutaoeoas  nerve.     6,  Short  sapliena  vein  and  nerve. 


the  stump,  and  the  uneven  surface  which  the  noi-mal  articular  face  of  the 
fem^^r  presents,  are  not  objectionable,  since  in  no  properly  constructed 
artificial  liml)  is  pressure  brought  upon  the  end  of  the  stump,  but  on 
the  ischio-perineal  region. 

Second  Method — Operation  of  Prof.  Stephen  Smith. — With  a  large 
scalpel  commence  an  incision  about  an  inch  below  the  tubercle  of  the 
tibia,  and  cut  to  the  bone ;  carry  it  downward  and  forward  beyond  the 
curve  of  the  side  of  the  leg,  thence  inward  and  backward  to  the  middle 
of  the  leg,  thence  upward  to  the  middle  of  the  popliteal  space ;  repeat 


AMPUTATIONS. 


147 


^/ 


::P^ 


Xti 


:^it' 


lAV^r-i 


i^tS^ 


;>..l 


-  ,^' 


'  A-< 


)-tm 


mm 


f< 


4\ 


V%a 


//. 


c^'^; 


A^'^i 


,^^' 


f'7^1 


?!•: 


C,^' 


^v^^^>' 


^v 


"1, 


1^. 


Fig.  234. — Section  through  upper  third  of  right  leg.  Surface  nearest  tlic  body.  1,  Anterior  tibial  vessels 
and  nerve.  2,  Posterior  ditto.  3,  Peroneal  vessels.  4,  Musculo-cutaneous  nerve.  5,  Internal  saphena 
vein  and  nerve. 

this  incision  upon  the  opposite  side ;  raise  the  flap,  consisting  of  all  the 
tissues,  down  to  the  bone  until  the  articulation  is  reached,  divide  the 


\, 


Fio.  235.— (Modified  from  Esmiireh.) 

liffaments,  and  remove  the  leg  as  in  the  ])revious  operation  (Fig.  237). 
The  flap  should  be  lifted  ivom  the  patella,  and  this  bone  removed. 

"Care  should  be  taken  that  the  incision  is  inclined  moderately  for- 
ward down  to  the  curve  of  the  side  of  the  leg,  to  secure  ample  covering 


148  A  TEXT-BOOK   ON   SURGERY. 

for  the  condyles,  and  that  upon  the  internal  aspect  it  should  have  addi- 
tional fullness  for  the  purpose  of  insuring  sufficient  iiap  for  the  internal 
or  larger  condyle"  (Smith). 

After  the  flaps  are  stitched  the  drain- 
age-tube makes  its  exit  through  the 
upper  posterior  angle  of  the  wound.* 


Fig.  236. — (After  Esmarch.)  Fio.  iST. 

Thigh. — Tlie  method  to  be  selected  in  amputations  through  the 
lower  two  thirds  of  the  thigh  will  depend  iipon  the  size  of  the  mem- 
ber at  the  point  of  election.  In  limbs  of  ordinary  size,  and  particu- 
larly in  emaciated  persons,  the  operation  advised  in  the  arm  should  be 
followed  here. 

First  Method. — Below  the  Ihie  of  section  through  the  femur,  at  a  dis- 
tance sufficient  to  furnish  an  ample  flap,  by  a  circular  incision  divide  the 
integument  down  to  the  muscles,  allow  the  skin  to  retract,  and  at  the 
line  of  retraction  divide  the  remaining  soft  tissues  down  to  the  bone. 
On  the  anterior  and  external  aspect  of  the  thigh,  by  a  perpendicular 
incision  extending  as  high  as  the  i:)oint  of  section  of  the  bone,  divide 
everything  to  the  bone,  and  from  the  periosteum,  with  a  dry  dissector, 
lift  the  solid  flap.  Apply  the  cloth  retractor  and  saw  through  the  bone. 
As  the  stump  is  placed  in  an  elevated  position,  with  the  thigh  also 
abducted  and  rotated  outward,  the  drainage  is  naturally  at  the  upper 
angle  of  the  perpendicular  incision.  This  same  iirocedure  may  be  carried 
out  in  this  class  of  cases  in  all  parts  of  the  thigh,  and  in  disarticulation 
at  the  hip-joint  as  well. 

When  the  diameter  of  the  limb  is  great,  or  when  there  is  abundant 
subcutaneous  areolar  tissue,  the  modified  circular  skin-flap  operation  is 
preferable. 

*  Tlie  method  of  Carden — namely,  long  anterior  skin-flap,  and  tlie  short  posterior  skin  and 
muscular  flap,  made  by  the  lonp  knife  carried  tliroush  the  joint — is  inferior  in  every  respect  to 
either  of  the  forejroing  operations.  Carden  recommended  section  through  the  condyles. 
Gritti  introduced  an  osteoplastic  modification  by  making  a  long  rectangular  skin-flap  from 
the  front  of  the  knee  and  leg,  which  is  dissected  up  deeply,  lifting  the  patella  in  the  flap. 
Behind,  a  short  flap  is  made  simihar  to  that  in  Carden^)  method.  Section  is  made  through 
the  bone  about  an  inch  above  the  tip  of  the  internal  condyle,  and  the  articular  surface  of  the 
patella  is  then  sawn  off.  This  procedure  may  be  best  accomplished  by  grasping  the  flap  with 
the  left  hand  and  stretching  it  over  the  knuckles,  so  that  the  articular  surface  of  the  patella 
looks  directly  upward,  where  it  is  fixed  quite  immovably.  As  the  flaps  are  adjusted,  the 
sawn  snrface  of  this  bone  is  brought  into  contact  with  that  of  the  femur.  Some  operators 
secure  it  here  by  transfixing  with  an  ivory  pin.  The  whole  procedure  is  not  only  difficult  and 
tedious,  but  wholly  unnecessary. 


AMPUTATIONS. 


149 


Second  Method. — Make  a  circular  incision  through  the  skin  and  fascia, 
joined  by  a  perpendicular  cut  on  the  lower  external  aspect  of  the  limb. 
Dissect  up  tiie  flap  from  the  muscles,  and  divide  all  the  remaining  soft 
tissues  squarely  at  the  point  of  section  of  the  bone.  Suture  the  flap, 
and  drain  from  the  outer  upper  (and,  if  necessary,  lower)  angle. 


Fio.  238.— Section  tlirousrh  the  riglit  femur  at  the  condyles  and  at  the  middle  of  the  patella.  Looking  at  the 
central  surf^ice  as  o.xrosed  altei-  amputation  at  this  point.  1,  Popliteal  artery,  vein,  and  internal  popliteal 
nerve.  2,  E.xtcmal  popliteal  or  peroneal  nerve.  The  capsule  and  the  synovial  cavities  arc  admirably 
shown,  as  well  us  the  bursa  mucosa  paUllce. 

At  the  Hip. — AVhen  possible,  the  first  method  just  given  should  be 
employed  here,  for  the  reason  that  it  allows  the  division  of  the  arteries 
at  the  greatest  possible  distance  from  the  trunk.  Proceed  as  follows : 
Place  the  patient  so  that  the  hip  at  which  the  operation  is  to  be  per- 
formed projects  well  over  the  corner  of  the  table.  The  member  to  be 
amputated  is  emptied  of  blood  by  elevation  and  the  Esmarch  bandage, 
and  is  held  by  an  assistant  while  the  opposite  thigh  is  abducted  and 
allowed  to  drop  over  the  end  of  the  table,  the  foot  resting  upon  a  stool. 
Hsemorrhage  may  in  great  part  be  controlled  by  placing  a  compress  iipon 
the  iliac,  as  it  runs  along  the  rim  of  the  pelvis,  and  holding  this  down 


150 


A  TEXT-BOOK  ON   SURGERY. 


and  in  position  by  a  strong  rubber  tubt',  carried  obliquely  around  the 
groin  from  the  perinseum,  above  the  anterior  spine,  and  over  the  crest  of 
the  ilium.  An  abdominal  tourniquet  should  be  applied,  so  as  to  com- 
press the  aorta  at  a  point  one  inch  to  the  left  of  the  umbilicus.  This 
need  not  be  tightened  unless  compression  below  proves  inadequate.* 

Operation. — Half  way  between  the  anterior-superif)r  spine  of  tlie  ilium 
and  the  npper  surface  of  the  trochanter  major  (the  extremity  being  held 
parallel  with  the  axis  of  the  body,  and  the  foot  normally  everted)  intro- 
duce a  strong  scalpel  straight  down  to  the  bone,  and  by  a  single  incision 
divide  all  the  tissues  along  the  head  and  neck,  over  the  nuddle  of  the 
great  trochanter,  and  down  the  outer  aspect  of  the  femur  lor  three  or  four 
inches,  and  as  much  as  six  if  possible,  below  the  tip  of  the  trochanter. 
Arrest  the  bleeding  as  the   operation   proceeds.      Dissect   the  tendons 


Fio.  239. — (Modified  from  Esmarch.) 


from  their  insertion  into  and  near  the  trochanter,  using  the  cutting  edge 
of  the  knife  only  when  necessary,  preference  being  given  to  lifting  the 
soft  parts  from  the  periosteum  and  capsule  with  the  dry  dissector.  With 
strong  hook  retractors  the  edges  of  the  wound  are  separated,  the  joint 
exposed,  the  capsule  and  ligamentum  teres  divided,  and  disarticulation 
effected.  The  soft  parts  are  now  still  farther  lifted  from  the  bone,  to  a 
point  at  least  six  inches  below  the  trochanter.     The  entire  mass  of  soft 

*  If  no  other  means  is  at  hand,  the  iliac  may  be  compressed  by  introducing  a  padded  statf 
into  tlie  rectum,  and  over  this  vessel  as  it  runs  along  the  pelvic  rim. 

Trendelenburg  recommended  transfixion  by  means  of  a  round  steel  pin,  which  is  passed 
between  the  head  of  the  femur  and  the  femoral  vessels.  Compression  is  maintained  by  the 
elastic  bandage,  thrown  over  the  end  in  figure-of-8  fashion. 


A3IPUTATI0NS. 


151 


tissues  is  now  constricted  by  a  second  elastic  tube,  or  ligature,  as  close  to 
tiie  body  as  possible,  and  tiiis  intrusted  to  an  assistant,  whose  hands  also 
grasp  that  part  of  the  tiap  in  whicli  the  large  vessels  are  located.  At  a 
jioint  as  low  as  possible,  or  about  six 
inches  from  the  trochanter,  make  a 
circular  sweep  around  the  thigh, 
dividing  the  sldn,  and  allow  this  to 
retract.  On  this  level  the  amputa- 
tion is  to  be  completed  by  passin'g  a 
long  knife  behind  the  bone,  cutting 
squarely  back  through  all  the  re- 
maining tissues  (Fig.  239).  As  rap- 
idly as  possible  all  the  larger  vessels 
are  grasped  with  forceps,  after  which 
the  ligatures  are  applied.  The  drain- 
age should  be  from  the  cavity  of  the 
acetabulum,  out  at  the  upper  angle, 
and  at  each  of  the  two  lower  angles 
of  this  stump. 

Second    MetJiod. — Six    or    seven 
inches  below  the  trochanter  make  a 

circular  incisioai  through  the  skin  and  fascia,  and  allow  this  to  retract. 
At  the  level  of  the  retracted  skin  divide  all  the  tissues  down  to  the  bone, 
and  saw  through  the  femur  at  this  level,  as  in  Dietfenbach's  procedure. 


Fio.  240.— (After  Esmarcb.) 


Secure  all  vessels  at  once,  and  disarticulate  by  the  same  incision  as  prac- 
ticed in  the  preceding  operation. 

Third  MetJiod  (Erskine  Mason's  Operation  *).  —The  circulation  is  con- 


♦  "  New  York  Mi.d'n.^al  Journal,"  December,  1876. 


152 


A  TEXT-BOOK   ON   SURGERY. 


trolled  by  the  abdominal  tourniquet,  Esmarch's  bandage  having  been 
applied  up  to  the  line  of  incision.  About  seven  inches  below  the  level 
of  the  joint  make  a  cin-ular  incision  through  tlie  skin,  turn  and  dissect 
this  up  as  high  as  the  head  of  the  femur.     With  the  scalpel  divide  the 


Fkj.  242.— Section  through  risht  thigh  at  Hunter'.s  canal.    Looking  at  tlie  surface  att.nched  to  the  body.    1,  Fem- 
oral vessels  and  long  saphenous  nerve.     2,  Great  sciatic  nerve  and  aitcria  comes.    3,  Long  sapliena  vein. 

muscles  on  this  plane,  open  the  capsule,  and  dislocate  the  femur.     The 
anterior  vessels  should  be  first  secured. 

Fourth  Method— Transfixion.— X  knife,  the  blade  of  which  should 
be  at  least  fifteen  inches  long,  is  introduced  half-way  between  the  tro- 
chanter major  and  the   anterior-superior  iliac  spine,   the   thigh   being 


AMPUTATIONS. 


153 


slightly  abducted  and  the  foot  in  the  normal  degree  of  eversion.  The 
blade  is  held  at  an  angle  of  90°  to  the  axis  of  the  body,  until  the  point  is 
felt  to  stiike  and  pass  into  the  capsule  of  the  joint,  when  the  handle  is 
elevated,  so  that  the  knife  is  parallel  with  Poupart's  ligament,  and  so 
directed  that  its  point  vnW  emerge  on  the  inner  aspect  of  the  thigh,  near 
the  perinseum  (Fig.  240).  As  the  last  step  in  this  mancpuvre  is  being 
effected  tlie  thigh  should  be  slightly  flexed  on  the  abdomen,  in  order  to 


Fio.  243. — Section  throuih  left  tliish  at  its  middle.  Looking  at  the  surfiice  attached  to  the  body.  1, 
Surcrficial  femoral  artery,  vein,  and  saphenous  nerve.  2,  Great  sciatic  nerve,  and  the  arteria  comes 
nervi  iscliiadici.  3,  Terminal  branch  ot'iirofunda  t'emoris.  4,  Descending  branch  of  external  circumflex. 
5,  Long  saphenous  vein. 

relax  the  tissues  here  and  allow  the  knife  to  pass  well  beneath  the  great 
vessels.  Two  precautions  are  necessary,  namely,  not  to  push  the  knife- 
point into  the  obturator  foramen,  and  also  to  avoid  wounding  the  sctotum 
or  labium.  By  to-and-fro  sweeps  of  the  knife,  which  is  made  to  pass 
along  upon  the  bone  for  about  seven  inches,  a  flap  about  eight  inches  in 
length  is  cut  on  the  anterior  and  inner  aspect  of  the  thigh.     As  soon  as 


154 


A  TEXT-BOOK   ON   SURGERY. 


the  knife  shall  have  traveled  downward  a  sufficient  distance  to  permit  it, 
an  assistant  should  insert  liis  middle-  and  index-tingers  into  the  wound, 
and,  with  the  aid  of  the  tliumhs  applied  externally,  control  the  vessels 
by  direct  pressure.  The  two  femoral  arteries  and  veins  should  be  at 
once  secured. 

The  cnpsule  should  now  be  divided  with  a  short,  strong  scalpel,  the 
head  of  the  bone  forcibly  luxated,  the  long  knife  laid  across  tin;  wound 
behind  the  caput  femoris,  and  a  short  Hap  formed  by  cutting  along  the 


FiQ.  244. — Section  tlirou;^h  left  thijjh  in  the  upper  third.     1,  Superficial  femoral  artery,  vein,  and  sapbcna 
nerve.     2,  Deep  femoral  vessels ;  near  by  the  obturator  nerve  and  vessels.    3,  Sciatic  iiervc  and  vessels. 


posterior  surface  of  the  femur  as  far  down  as  one  inch  beyond  the  gluteal 
fold  (Fig.  241). 

Of  the.se  various  procedures  at  the  hip,  the  first,  although  requiring 
more  time  for  its  performance,  should  be  preferred,  since  the  greatest  of 
all  dangers  in  this  operation — hsemorrhage — is  jiractically  avoided.  In 
fat  subjects,  or  where  the  muscular  development  is  very  great,  the  pro- 
cedure of  Mason  should  be  followed.  When  rapidity  of  execution  ia 
essential,  the  fourth,  or  transfixion  method,  is  preferable. 


AMPUTATIONS. 


155 


Fig.  245. — Transverse  section  of  left  thigh  throutfh  lesser  trochanter.  Lookina  from  helow  upward.  1, 
Saphenous  vein.  2,  Superficial  femo'ral  vein  and  ai-tcry.  3,  I'rofunda  femoral  vein  and  artery,  anterior 
crural  nerve  between  the  two  arteries.    4,  Obturator  nerve  and  artery.     5,  Sciatic  nerve  and  artery. 

Note. — The  following  summaries,  compiled  by  Dr.  F.  C.  Sheppard,  are  taken  from  Prof. 
Ashhurst's  article  in  the  "  Eucyclopiedia  of  Surgery."  *  It  is  safe  to  assert  that  the  improved 
methods  of  htemostasis  and  antisepsis  will  yield  a  lighter  rate  of  mortality,  in  both  military  and 
civil  practice,  than  that  shown  by  a  study  of  these  tables. 


I.  Summary  of  Two  Hundred  and  Thirtu-eight  Cases  of  Hip-joint  Amputation  in 

Military  Practice. 


NATURE   OF  OPERATION. 

Recovered. 

Died. 

Undeter- 
mined. 

Total 

Mortailty 
per  cent 

Primary .        

7 
4 
10 
4 
5 

89 
59 
17 
3 
39 

0 
0 
0 

0 

1 

96 
63 
27 
7 
45 

92-7 

93-6 

Secondary 

62-9 

Reamputatioa  of  thigh-stump. .  . . 
Not  stated 

42-8 
88-6 

Total  number  of  cases 

30 

207 

1 

238 

87-3 

*  William  Wood  &  Co.,  New  York,  1881. 


156 


A   TEXT-BOOK  ON   SURGERY. 


Fio.  246. — Section  throujh  the  left  hip.  Looking  from  helow  upward.  Reduced  from  life  size.  1,  Fem- 
oral vein,  artery,  and  crural  nerve  in  order  fmm  within  outward.  2,  Great  sciatic  nerve,  artery,  and 
vein.     3,  Epigastric  vein.     4,  Vessels  to  acetabulum. 


II.  Summary  of  Seventy-one  Cases  of  Hip-Joint  Amputation  for  Injury  in  Civil 

Practice. 


NATUKF,  OF  OPEEATION. 

Kccovered. 

Died. 

Totol. 

Mortality 
per  cent. 

Primarv 

6 
5 
5 

4 
4 

25 

7 
6 

1 
8 

31 
12 
11 
5 
12 

80*6 

Intermediate 

Secondarv 

58 -.3 
54-5 

Reamputation  of  thigh-stuint) 

20-0 

Not  stated 

66  6 

Total  number  of  cases 

24 

47 

71 

66-1 

III.  Summary  of  Tico  Hundred  and  Seventy-six  Cases  of  Hip-joint  Amputation  for 

Disease. 


KATUEE  OF  OPEEATION. 

Kccovered. 

Died. 

Undeter- 
mined. 

Total. 

Mortality 
per  cent. 

Amputation  of  entii-e  limb 

Reamputation  of  tliigli-stump 

136 
20 

95 
10 

14 
1 

245 
81 

41-1 
33-3 

Total  number  of  cases 

i.^e 

105 

15                    971! 

40''' 

AMPUTATIONS. 


157 


IV.  Summary  of  Forty-eight  Cases  of  Hip-joint  Amputation  for  Unkiioicn  Causes. 

Eecovered. 

Died. 

Cndeter- 
mined. 

Total.                 Mortality 
per  cent.' 

Number  of  cases 

10 

34 

4 

48                77-2 

V.  General  Summary  of  Six  Hundred  and  Thirty-three  Cases  of  Hip-Joint  Ampu- 
tation for  all  Causes. 


NAT0EE  OF  CASE. 

Recovered. 

Died. 

Undeter- 
mined. 

Total. 

MorUlity 
perccnL 

156 
54 
10 

105 

254 

34 

15 
1 
4 

276 

309 

48 

40-2 

Tra\iiuatic 

Cause  unknown 

82-4 

77-2 

Total 

220 

393 

20 

633 

641 

*  Undetermined  cases  omitted  in  computing  percentages. 


CHAPTER  IX. 

the  surgical  diseases,  and   sttrgert  of  the   lymphatic  vessels, 

veins,  and  arteries. 

The  Lymphatic  System. — Lymphangitis. 

The  pathological  conditions  in  inilammation  of  the  lymphatic  vessels 
closely  resemble  those  of  the  veins,  with  which  they  are  intimately  asso- 
ciated. The  histology  of  the  two  systems  is  almost  identical.  One  essen- 
tial point  of  difference,  and  one  which  has  a  pathological  significance,  is 
that  the  lymphatic  vessels  are  practically  closed  tubes,  since  at  varying 
intervals  in  their  route  to  the  center  each  trunk  breaks  lap  into  small  and 
smaller  branches,  until  they  end  in  closed  capillaries  in  the  substance  of 
a  lymphatic  gland.  Although  it  is  not  yet  positively  proven  that  there 
is  no  direct  communication  between  the  afferent  and  efferent  vessels,  the 
weight  of  evidence  is  in  favor  of  the  theory  that  the  vessels  end  and  begin 
as  closed  tubes.  It  follows  that  whatever  of  septic  or  intiammatory 
matter  may  pass  into  these  vessels,  it  can  not  rapidly  enter  the  systemic 
circulation.  Each  lymphatic  gland  is  a  sieve  which  arrests  its  i^rogress 
and  modifies  its  effect.  In  the  venous  system,  however,  there  is  no 
resistance  to  rapid  and  direct  systemic  infection.  We  conclude,  then,  on 
anatomical  grounds,  as  well  as  from  clinical  experience,  that  the  effects 
of  phlebitis  are  more  rapidly  felt,  and  in  general  more  disastrous,  than 
those  of  lymphangitis. 

Lymphangitis  means  an  inflammation  of  all  the  stnictures  which 
make  up  the  wall  of  a  lymph-carrying  vessel ;  the  endothelial  lining,  the 
musctilar  and  connective  tissues,  are  involved.  Hypersemia  and  thicken- 
ing occur,  with  or  without  coagulation  of  the  lymph  and  occlusion  of  the 
ducts.  As  in  other  inflammatory  jirocesses,  the  native  and  wandering 
cells  undergo  proliferation,  and  form  in  the  extra-vascular  spaces  a  com- 
mon embryonic  tissue,  which,  under  certain  favorable  conditions,  may 
undergo  gi-anular  metamorphosis  and  absorj^tion  (resolution),  or,  if  the 
process  be  violent  and  the  tissues  of  a  low  order  of  vitality,  suppuration 
may  occur.  Lymphangitis  may  be  traumatic  in  origin,  or  result  as  a  part 
of  some  idiopathic  inflammation.  It  may  also  be  described  as  an  acute, 
subacute,  and  chronic  disease,  involving  the  superficial  or  deep  vessels, 
or  both. 

The  symptoms  of  acute  lymphangitis,  while  varying  in  intensity  pro- 
portionate to  the  virulence  of  the  cause  and  the  condition  of  the  tissues 


THE   LYMPHATIC   SYSTEM.  159 

affected,  are  the  same  in  the  essential  features  in  every  case.  Following 
an  inoculation  with  any  septic  matter,  within  a  few  hours  there  is  a 
sense  of  uneasiness  and  burning  in  the  immediate  vicinity  of  the  wound. 
Pain  is  not  usually  severe  until  the  swelling  is  well  marked.  At  the  end 
of  from  twenty-four  to  thirty-six  hours  the  injection  of  the  suiiei-ficial 
vessels  which  lead  from  the  local  inflammation  toward  the  center  may  be 
recognized.  These  red  lines  give  a  i)eculiar  sensation  to  the  touch. 
While  the  outline  of  the  vessel  can  rarely  be  made  out  by  palpation, 
there  is  often  an  appreciable  thickening  and  tension  in  the  tissues  imme- 
diately over  and  around  it.  Pain  is  present  in  some  instances,  while  in 
others  even  direct  and  strong  pressure  causes  little  or  no  disturbance. 
When  the  nearest  gland  or  plexus  is  reached  by  the  inflammatory  pro- 
cess, by  pressure  upon  these  a  sharj)  sense  of  jjain  is  experienced.  The 
febrile  movement,  wliich  may  ensue  within  twenty-four  hoiirs,  though 
usually  not  well  marked  at  this  early  period,  is  generally  introduced  by 
a  chill  or  a  series  of  chilly  sensations,  characterized  by  pallor  and  the 
"picked-goose"  roughness  of  the  skin.  The  temperature  rises  rai)idly 
above  the  normal,  and  may  reach  a  high  degree.  Nausea,  vomiting, 
delirium,  and  the  train  of  symptums  wliich  accompany  septic;emia  may 
follow ;  but  this  is,  fortunately,  tlie  exception.  If  the  conditions  are 
unfavorable  to  the  progi'ess  of  the  disease,  the  temperature  declines  gradu- 
ally, resolution  occurs,  and  the  symptoms  of  inflammation  disappear  in 
from  one  to  two  weeks. 

In  the  diagnosis  of  lympliangitis  it  is  well  to  bear  in  mind  that  in 
pJilebitis  the  lines  of  red  discoloration  are  wider  than  in  the  disease 
under  consideration,  that  there  is  a  more  general  condition  of  oedema, 
that  the  Lines  of  inflammation  follow  well-known  and  appreciable  veins, 
that  these  veins  are  very  painful  to  pressure,  and  that  they  are  easily 
recognized  as  hard,  semi-elastic,  knotty  cords. 

In  erythema^  erysipelas,  and  dermatitis  the  discoloration  is  deep  and 
diffuse,  and  the  supeiiicial  lymi^hangitis  which  exists  can  not  be  made 
out  in  the  general  staining.  It  is  evident,  however,  in  one  unfailing 
symi)tom — adenitis  in  the  glands  in  the  direct  route  of  the  vessels. 

The  treatment  is  local  and  general.  Cold  applications  are  preferable, 
if  cold  is  agreeable  to  the  patient.  Employ  the  ice  or  cold-water  bag,  or 
cold  cloths.  Heat  may  be  applied  in  a  similar  manner.  The  sense  of 
comfort  experienced  is  the  only  criterion  in  determining  the  employment 
of  these  agencies.  The  lead  and  ojiium  wash  is  a  valuable  remedy. 
When  an  extremity  is  affected  it  should  be  kept  in  perfect  repose  and 
in  an  elevated  position.  If  suppuration  occurs,  the  pus  should  be  evacu- 
ated. If  cellulitis  and  great  tension  complicate  the  lymphangitis,  make 
free  parallel  incisicms  to  obviate  threatened  strangulation.  The  consti- 
tutional remedies  look  to  the  regulation  of  the  alimentary  apparatus — 
quinia,  iron,  etc.,- and,  above  all,  pure  air  and  cheerful  surroundings. 

Subacute  and  citron ic  lymphangitis  are  associated  with  forms  of  gen- 
eral systemic  infection,  as  in  syphilis,  which  is  typical  of  the  subacute 
variety,  and  in  "Hodgkin's  disease"  and  the  so-called  scrofulous  dys- 
crasia,  which  are  chronic  forms  of  this  disease. 


160  A  TEXT-BOOK   ON   SURGERY. 

Adenitis,  or  inflammation  of  a  lymphatic  gland,  usually  exists  with 
the  disease  just  considered,  or  it  may  be  independent  of  it. 

The  pathological  cJianges  vary  as  the  process  is  acute,  finhacute,  or 
chronic.  In  acute  adenitis  tlie  cells  of  tlie  reticulum  and  the  leucocytes 
proliferate  with  great  rapidity,  resulting  in  pressure  upon,  and  occlusion 
of,  the  periglandular  blood-vessels,  and  consequent  suppiu'ation.  In  the 
subacute  and  chronic  forms  the  proliferation  is  confined  cliietly  to  the 
connective- tissue  cells  of  the  reticulum,  or  net-work  of  the  gland,  causing 
an  abnormal  thickening  of  the  stroma,  and  a  diminution  of  the  corpuscu- 
lar elements  of  the  gland. 

Acute  adenitis  may  result  from  a  blow,  from  excessive  muscular 
action,  or,  as  above  stated,  it  may  follow  an  acute  lymphangitis. 

The  si/mptoms  are  a  sense  of  soreness  and  tension,  sharp  throbbing 
pain,  increased  on  slight  pressure,  swelling,  and  redness  of  the  super- 
jacent skin.  The  suppuration  commences  in  the  center  of  the  gland, 
and  gradually  extends  until  the  tissues  around  are  involved.  The  con- 
stitutional symptoms  are  similar  to  those  given  in  lymphangitis.  If  the 
inflammatory  process  be  of  the  subacute  form,  the  enlargement  is  more 
gradual,  and  pain  and  the  other  symptoms  of  acute  adenitis  are  absent. 
Examined  microscopicallj",  the  tumor  will  be  found  to  be  composed  of 
cellular  elements,  varying  in  size  and  conformation  from  that  of  the 
normal  lymphatic  corpuscle  to  the  giant  cell.  Later  in  the  history  of 
this  process  fatty  and  caseous  degenerations  may  occur,  ending  in  resolu- 
tion or  suppuration.  In  chronic  adenitis  the  tumors  are  more  solid  and 
firmer  to  the  touch,  since  the  enlargement  is  due  in  greater  part  to  the 
proliferation  and  hyperplasia  of  the  connective-tissue  stroma. 

In  the  treatment  of  acute  adenitis  perfect  quiet  must  be  enforced. 
Local  applications  are  indicated  as  in  lymphangitis.  If  suj^puration  is 
evident,  early  incision  is  indicated.  The  process  of  repair  is  usually  slow. 
Frequently  one  after  another  of  the  glands  in  a  group  breaks  down  in  the 
process  of  suppuration,  forming  sinuses  which  undermine  the  neighbor- 
ing tissues,  when  it  is  necessary  to  lay  each  abscess  open  freely  and 
scrape  out  every  particle  of  diseased  tissue  with  a  Volkmann's  spoon. 
Thus  treated,  the  wound  should  be  packed  with  sublimate  gauze,  and 
treated  as  an  open  wound  throughout. 

Chronic  enlargements  of  the  lymphatic  glands  require  chiefly  consti- 
tutional treatment.  Local  measures  may  be  deemed  advisable,  in  order 
to  protect  the  part  from  pressure.  Plasters  of  mercury,  belladonna,  or 
galbanum,  are  among  the  most  useful  remedies  of  this  kind.  The  jilaster 
may  be  changed  at  intervals  of  two  or  three  days.  Painting  with  tincture 
of  iodine  is  painful,  and  of  doubtful  benefit.  Among  constitutional  reme- 
dies the  protoiodide  of  mercury,  combined  with  tonics  and  proper  ali- 
mentation, will  in  general  prove  most  satisfactory. 

Wonnds  of  the  lymphatic  vessels  may  occur  in  common  with  solutions 
of  continuity  in  other  tissues.  The  escape  of  lym]ih,  and  occlusion  of  the 
vessels  involved,  back  to  the  first  collateral  branch,  is  the  rule,  as  with 
the  blood-vessels.  If  the  vessel  be  large,  as  when  the  deeper  channels  of 
the  leg  or  the  thoracic  duct  is  divided,  the  ligature  or  compression  of  the 


PHLEBITIS.  161 

distal  end  is  necessary  to  prevent  a  lympli  fistula.  It  has  been  demon- 
strated that  tlie  lymph  and  chyle  can  be  carried  into  the  circulation  by 
collateral  routes,  after  occlusion  even  of  the  thoracic  duct. 

Varicosities  occur  at  times  in  the  lymphatic  vessels,  as  in  the  veins. 
The  causes  and  treatment  are  essentially  the  same.  As  a  result  of  ob- 
struction, in  some  instances,  cystic  dilatations  occur,  which,  according 
to  Bellamy,*  are  usually  found  in  the  tongue,  lips,  and  about  the  neck. 
Hydromata  of  the  neck  are  at  times  congenital.  In  their  structure  they 
are  trabeculated,  the  caverns  filled  with  lymph.  The  location  is  beneath 
the  occiput,  and  the  tumor  is  sjnnmetrical,  the  cyst  of  each  side  of  the 
median  line  being  lined  with  lymphatic  endothelia. 

New  formations  (lymphomata)  of  lymphatic  vessels  occur  occasionally, 
and  blood-vessels  developing  in  these  give  rise  to  a  mixed  new  gi'owth, 
known  as  lympho-angeioma. 


Phlebitis,  t 

Definition  and  Morbid  Anatomy. — PhleMtls  means  an  inflamma- 
tion of  all  the  tissues  which  enter  into  the  formation  of  the  walls  of  a 
vein.  Endophlebitis,  mesojyMebitis,  and  periphlebitis  are  terms  used  to 
designate  the  inflammatory  process  involving  respectively  the  internal, 
middle,  and  external  layers  of  the  venous  wall. 

The  progress  of  inflammation  in  the  tissues  of  veins  is  closely  analo- 
gous to  that  of  the  same  process  in  all  other  structures,  namely,  inita- 
tion,  hyperemia,  tumefaction,  infiltration  of  the  extra-vascular  spaces 
with  emigi-ant,  embryonic,  and  i)us  cells ;  the  proce.ss  terminating  in 
cicatrization  (often  with  adhesions),  calcareous  degeneration,  suppuration, 
or  gangrene.  The  mode  of  termination  will  depend  upon  the  severity  of 
the  attack,  the  character  of  the  lesion,  and  the  power  of  resistance  and 
recuperation  existing  in  the  tissues.  The  inflammatory  process  involves 
a  tubular  structure,  the  waUs  of  which  are  composed  of  an  inner  layer 
{iritimax  made  np  of  flat,  polygonal  cells  (the  endothelia),  a  middle  layer 
chiefly  made  up  of  elastic  tissue,  and  an  outer  layer,  containing  elastic 
loops,  connective  tissue,  and  unstriped  muscle.  Blood-vessels  and  nerves 
traverse  the  outer  and  middle  tunics,  following  the  bundles  of  connective 
tissue. 

The  cells  of  the  lining  membrane  are  smaller  than  the  arterial  endo- 
thelia, and  are  imbedded  in  a  fil)rillated,  intercellular  substance  (Cornil 
and  Ranvier).  The  elastic  and  muscular  tissues  are  less  developed  than 
in  the  arteries  (Heitzmann).  Tliese  are  so  irregularly  arranged  that  any 
division  into  middle  and  external  coats  is,  in  great  part,  artificial  and 
imaginary.      Moreover,  many  of  the  veins  contain  no  muscular  tissue, 

*  ■'  Encydopicrlia  of  Surgery,"  vol.  iii,  p.  34,  Aslilnirst.     William  Wood  &  Co.,  1883. 

t  That  portion  of  this  chapter  between  pages  IGl  and  198  is  taken  from  my  article  in  the 
"  International  EncyclopiBdia  of  Snrgery,"  edited  by  Prof.  John  Ashhurst,  Jr.,  .M.  D. ;  pub- 
lished by  Messrs.  William  Wood  &  Co.,  of  Xew  York  city,  for  whoso  kind  permission  to  intro- 
duce it  in  this  book  in  its  original  form  the  author  begs  to  make  his  sincere  acknowledgment. 
11 


162  A  TEXT-BOOK   ON   SURGERY. 


while  their  connective  tissue  varies  in  (|uantity  in  different  jKirts  of  tlic 
body.  Tlie  sinuses  of  tlie  dura  mater,  the  veins  in  bones,  and  those  of 
the  retina,  have  no  muscular  libers,  wliile  tlie  juii;ulars,  subclavians,  and 
venae  cavjc  have  a  relatively  small  quantity,  or  are  entirely  devoid  of  this 
tissue.  Af^aiu,  the  arrangement  of  tlie  muscular  tissue  differs  in  different 
veins.  The  inferior  vena  cava  and  the  portal  and  renal  veins  have  an 
inner,  circular,  and  an  external,  longitudinal  layer,  while  the  femoral  and 
popliteal  veins  have  the  longitudinal  libers  more  internal.  This  tissue  is 
still  more  complicat(Ml  in  the  saphenous  veins,  where  the  internal  layers 
are  arranged  longitudinally,  with  a  numlKT  of  alternating,  or  transverse 
and  longitudinal,  layers  placed  externally  to  these. 

The  elastic  layer  begins  immediately  external  to  the  basement  sub- 
stance which  su])ports  the  endothelial  layer,  and  is  here  somewhat  iso- 
lated and  well  defined ;  but  from  the  external  surface  of  this  central, 
elastic  lamina  springs  a  net-work  of  elastic  fibers,  through  the  loops  and 
in  the  meshes  of  which  are  woven  the  muscular  and  connective-tissue 
fibers. 

The  vasa  vasorum  follow  the  connective-tissue  bundles  in  their  distri- 
bution to  the  tissues  of  the  wall  down  to  the  elastic  layer.  Nerves  from 
the  sympathetic  system  have  been  demonstrated  in  the  larger  veins. 

The  valves  are  delicate  reduplications  of  the  internal  coat,  having  a 
well-defined,  elastic  reticulum,  especially  on  their  distal  or  convex  sur- 
face (Heitzmann),  and  muscular  fibers  at  the  point  of  attachment  to  the 
venous  wall. 

The  vascular  area — the  outer  and  middle  layers — is  first  concerned  in 
the  infiammatory  process.  The  endothelial  tunic,  as  a  result  of  these 
structural  changes,  is  subsequently  involved  in  the  process.  It  then 
appears  cloudy,  thickened,  and  rough,  and  may  become  separated  in 
shreds.     (Prey.) 

In  the  vascular  area,  during  the  earlier  stages,  the  capillaries  of  the 
vasa  vasorum  become  swollen,  the  white  corpuscles  migrate  into  the 
extra-vascular  spaces,  and  the  normal  connective-tissue  (^ells  are  stimu- 
lated into  rapid  proliferation,  resulting  in  a  thickening  of  the  wall,  due 
to  the  presence  of  these  embryonic  cells,  and  the  excessive  hyperamda. 
As  in  arteritis,  the  vitality  of  the  endothelial  tunic  becomes  impaired, 
and  it  is  more  or  less  projected  into  the  cavity  of  the  vein,  the  endothelia 
undergoing  rapid  |)roliferation.  After  a  few  days,  granulation-buds  push 
out  from  this  eml)iyonic  tissue  of  the  endothelia,  and  new  capillaries  are 
developed  in  the  granulation  -  masses,  anastomosing  and  becominjj  a 
part  of  the  circulation  of  the  vasa  vasorum,  as  well  as  leading  into  the 
coagulum  which  occupies  the  caliber  of  the  vein. 

At  the  point  of  contact  of  the  outer  surface  of  the  thickened  endo- 
thelial layer  with  the  internal  surface  of  the  middle  (elastic)  layer,  large 
sinuses  are  developed,  which  receive  the  blood  from  the  capillaries  of  the 
middle  tunic.  These  sinuses  are  lined  with  an  endothelial  layer,  which 
rests  uj^on  the  contiguous  connective  tissue.  From  these  large  vessels 
fine  capillaries  are  given  off,  which  permeate  the  thickened  internal  layer, 
and  some  of  which  pass  into  the  organizing  coagulum. 


PHLEBITIS.  1(53 

When  a  thrombus,  caused  by  the  sudden  coagulation  of  the  blood  in 
a  vein,  is  examined  in  its  recent  state,  it  is  found  to  be  composed  of  suc- 
cessive laminae  of  fibrin  and  corpuscles,  and  the  more  recent  ol  these 
lamina?  are  external.  Wlien  the  vein  is  first  occluded  l)y  this  sudden 
coagulation  of  the  blood,  the  pressure  from  behind  is  so  great  that  the 
coagulum  is  compressed  toward  its  center,  while  the  current,  more  and 
more  impeded  in  its  progress,  flows  between  the  periphery  of  the  clot  and 
the  inner  surface  of  the  vessel,  adding,  layer  by  layer,  fresh  deposits  of 
coagulation  upon  the  thrombus.  A  microscopical  examination  of  such 
thrombi  reveals  a  vast  number  of  white  corjauscles  in  various  stages  of 
fatty  degeneration,  with  layers  of  fibrin  intervening. 

Exi^eriments  have  shown  that  not  only  does  the  inflammatory  pi'ocess, 
by  reason  of  its  invasion  of  the  intima,  produce  changes  in  the  blood 
which  lead  to  stasis,  but  that  thei'e  is  also  a  dangerous  endosmosis  of 
septic  matter,  which  is  swept  along  toward  the  heart  and  lodged  in  the 
capillaries  of  the  various  organs  {emboli),  producing  infarctions,  abscesses, 
and,  almost  invariably,  irreparable  damage.  The  adhesion  of  the  intima, 
and  the  formation  of  a  fibrinous  clot — which  may  completely  occlude  the 
vessel  {occlusion  tJirombus),  or  may  merely  plaster  over  the  endothelial 
tunic  {peripheral  thronibus) — are  efforts  toward  prevention  of  this  endos- 
mosis. 

The  process  of  repair  in  tissues  capable  of  successful  resistance,  i:i 
venous  inflammation,  is  one  of  organization  of  the  embryonic  cells,  fibril- 
lation, and  contraction,  resulting  in  partial  or  complete  occlusion.  In 
tissues  of  low  and  impaired  vitality,  the  progress  of  the  inflammation  is 
rapidly  toAvard  suppuration,  usually  terminating  in  septic  fever  and 
death.  Microscopical  sections  from  such  specimens  of  phlebitis  show 
that  the  leucocytes  and  embryonic  cells  have  undergone  retrogressive 
changes,  and  that  the  tissues  are  infiltrated  with  pus  corpuscles.  Gan- 
grenous sjjots  are  not  infrequent,  often  opening  into  the  caliber  of  the 
vessel,  and  allowing  the  influx  of  septic  jiroducts,  or  the  efflnx  of  blood. 

Since  phlebitis  is  a  frequent  cause  of  thrombosis,  and  since  venous 
thrombosis  is  the  most  frequent  form  of  intra-vascular  coagulation,  a 
consideration  of  the  pathogeny  and  pathology  of  this  process  must  natu- 
rally find  a  place  here.  Virchow  has  endeavored  to  show  that  primitive 
lihlebitis  is  extremely  rare,  and  that,  when  a  clot  is  produced  in  a  vein 
which  is  inflamed,  the  coagulation  has  more  often  preceded  than  followed 
the  inflammation.  Cornil  and  Ranvier,  from  whom  the  above  account  is 
taken,  do  not  accept  this  theory. 

Fibrin,  the  immediate  factor  in  coagulation  of  the  blood,  does  not 
exist  as  such  in  the  normal  condition  of  this  fluid.  Under  healthful  con- 
ditions, the  blood  would  circulate  always  without  any  deposit  of  fibrillated 
fibrin  in  the  economy.  Accoi'ding  to  Denis,  the  normal  plasma  of  the 
blood  can  be  separated  into  a  semi-solid  substance,  2^l(fsmi/ie,  and  a  liquid, 
serine.  Plasmine  is  further  separable  into  fibrin  and  metalbiimen,  and 
it  is  held  that  the  coagulation  of  the  blood  is  due  to  the  conversion  of 
plasmine  into  fibrin.  Foster  holds  that  coagulation  is  the  result  of  the 
interaction  of  two  bodies,  paraglobulin  and  fibrinogen,  brought  about 


164  A  TEXT-BOOK   OX  SURGERY. 

by  the  agency  of  a  third  body,  fibrin -ferment.  A.  Schmidt  has  carried 
experimentation  further,  and  is  led  to  believe  that  paraglobulin  and 
fibrin- ferment  lioth  originate  in  the  white  blood-corpuscles.  This  tlieory 
is  exceedingly  seductive,  and  it  can  not  be  denied  that  actual  pathology 
proves  that  around  and  within  inflammatory  areas  where  white  blood- 
corpuscles  are  most  abundant,  coagulation  and  fibrillation  are  more  apt  to 
occur,  and  a  study  of  thrombi,  which  have  been  gradually  formed,  reveals 
alternating  layers  of  white  corpuscles  and  fibrillated  fibrin.    (Green.) 

What  may  be  the  principle  in  the  blood  which  is  the  factor  of  coagula- 
tion, or  what  reaction  it  may  be  which  ])recipitates  the  fibrin,  we  can  not 
in  the  present  conditon  of  science  jiositively  assert.  The  facts,  however, 
"point  to  the  conclusion  that  when  blood  is  contained  in  healthy,  living 
blood-vessels,  a  certain  relation  or  equilibrium  exists  between  the  blood 
and  the  containing  vessels,  of  such  a  nature  that,  as  long  as  this 
equilibrium  is  maintained,  the  blood  remains  fluid  ;  but  when  this 
equilil)rium  is  disturbed  by  events  in  the  blood  or  blood-vessels  (or  by 
the  removal  of  the  blood),  it  undergoes  changes  which  result  in  coagu- 
lation."   (Foster.) 

So  delicate  is  the  sensibility  of  the  blood  to  mechanical  irritation  or 
hindrance  in  its  flow,  that  the  slightest  injury  or  roughening  of  the 
endothelial  lining  membrane  may  produce  a  deposit  of  fibrillated  fibrin. 
A  delicate  needle,  or  wire,  or  thread,  thrust  into  the  lumen  of  a  healthy 
vessel,  precipitates  coagulation  upon  the  foreign  body.  The  white  cor- 
puscles are  found  clustered  in  great  numbers  on  the  foreign  body,  and, 
when  the  mass  is  examined  with  the  microscope,  the  corpuscles  seem  to 
serve  as  starting-points  for  the  development  of  fibrin.     (Reichert.) 

Causes  and  Clinical  History  of  Phlebitis. — Phlebitis  has  been 
termed  traumatic  and  idiopathic,  and  the  latter  term  has  been  applied 
indiscriminately  to  all  forms  of  phlebitis  not  directly  due  to  an  appre- 
ciable lesion. 

Idiopathic  ijldebitis  is  comparatively  a  rare  affection  (Yirchow).  It 
may  occur  without  a  traumatism,  as  from  exposure  to  cold,  or  as  a  sequel 
to  fevers  and  varicosities  (Hamilton).  It  may  occur  as  a  complication  of 
syphilis  (Hutchinson),  or  as  a  result  of  the  gouty  diathesis  (Paget).  From 
whatever  cause  it  may  proceed,  idiopathic  phlebitis  usually  affects  the 
veins  of  the  lower  extremities. 

Traumatic  phlebitis  may  be  caused  by  a  partial  or  complete  solution 
of  continuity  of  the  venous  walls,  by  contiguity  of  inflamed  tissues,  or  by 
violent  muscular  action  and  pressure. 

The  inflammation  of  the  uterine  sinuses  during  and  after  parturition, 
which  Cornil  and  Ranvier  style  "la  phlebite  spontanee,"  is  really  a  fomi 
of  traumatic  phlebitis,  due  to  the  irritation  resulting  from  pressure  and 
muscular  action. 

Phlebitis  has  been  described  as  acute  and  chronic  (Gross) ;  adhesive 
and  suppurative  (Bryant) ;  gouty  and  diffuse  (Hamilton).  These  terms 
but  express  varying  conditions  of  one  pathological  process,  and  whether 
this  inflammatory  process  shall  result  in  adhesion  or  suppuration,  shall 
become  diffused,  or  shall  assume  a  chronic  form,  will  depend  solely  upon 


PHLEBITIS.  •  165 

the  character  and  cause  of  the  disease,  and  upon  the  capacity  of  the 
tissues  to  resist  its  progress. 

1.  Idiopathic  Phlebitis.  1.  ^yphiUUc  PJdeMtis. — Mr.  IIutchinsf)n 
lias  called  attention  to  the  very  few  cases  of  syphilitic  phlebitis  which 
have  been  recorded,  and  yet  he  says  that  most  surgeons  are  familiar  with 
the  fact  that  inflammations  around  varices,  and  even  about  otherwise 
healthy  veins,  are  not  infrequent  in  syphilitic  subjects.*  Mr.  Hutchin- 
son further  says:  "1  think  also  that  I  have  seen  several  cases  in  which 
the  thrombosis  and  phlebitis  were  attended  by  other  conditions  sufficiently 
peculiar  to  justify  a  belief  that  they  were  of  specific  origin.  In  some 
there  has  been  great  excess  of  infiammation,  a  large  hard  mass  forming 
in  the  cellular  tissue,  and  threatening  to  slough,  much  as  subcutaneous 
gummata  often  do.  These  cases  are  much  benefited  by  the  iodide  of  po- 
tassium, so  far  as  jirevention  of  -sloughing  is  concerned,  but  the  thrombotic 
plugging  remains."  f 

2.  Gouty  Phlebitis. — Subjects  (says  Mr.  Bryant)  who  are  gouty  from 
hereditary  or  acquired  causes  are  liable  to  phlebitis.  Paget  has  described 
the  affection  in  his  "Clmical  Lectures,"  and  Mr.  Gay  has  written  upon 
it.  In  such  cases  the  phlebitis  may  have  no  intrinsic  characters  l\v  which 
to  distinguish  it,  yet  not  rarely  it  has  peculiar  marks,  espeoiallj-  in  its 
cymmetry,  apparent  metastases,  and  frequent  recurrences.  Like  other 
forms,  it  is  more  common  in  the  lower  than  in  the  upper  extremities,  yet 
it  may  be  found  anywhere.  It  affects  the  superficial  rather  than  the 
deep  veins,  and  often  occurs  in  patches,  affecting  on  one  day,  for  example, 
a  short  x>iece  of  the  saphenous  vein,  and  the  next  another  portion  of  the 
same  vein,  some  other  distant  vein,  or  a  corresponding  piece  of  the  oppo- 
site vein. 

The  inflamed  portions  of  the  vein  usually  feel  hard  and  are  painful  to 
the  touch.  The  soft  parts  covering  the  vein  become  slightly  thickened, 
and  often  have  a  dusky,  reddish  tint.  When  the  deej)  veins  are  involved, 
oedema  appears,  with  the  well-recognized  results  of  obstruction  :  the  limb 
becomes  big,  clumsy,  featureless,  heavy,  and  stiff ;  its  skin  is  cool,  and 
may  be  pale,  but  more  often  has  a  slightlj'  livid  tint,  which  may  be  recog- 
nized by  comparison  with  the  other  limb ;  and  it  has  mottlings  from 
small  cutaneous  veins,  visibly  distended.  The  limb,  thus  enlarged,  feels 
oedematous  throughout,  but  firm  and  tight-skinned,  not  yielding  easily 
to  pressure,  and  not  pitting  very  deeply. 

The  constitutional  symptoms  associated  with  this  affection  vary  from 
some  slight  febrile  condition  to  those  met  with  in  acute  gout.  Comjjlete 
recovery  may  take  place  in  this  as  in  other  forms  of  phlebitis,  the  veins 
becoming  pervious  in  some  cases  and  obstructed  in  others.  The  risks  of 
embolism  are  also  the  same.     (Bryant.) 

3.  Acute  Idiopathic  PTtlebitis  (not  gouty  or  syphilitic). — This  form 
of  venous  inflammation — caused,  as  has  been  said,  by  exposure  to  cold, 
due  to  the  presence  of  a  varicosity,  or  coming  in  the  course  of  a  severe 
febrile  attack — may  involve  one  or  more  veins.     The  disease  travels  along 

*  J.  II.  C.  Sillies  aod  J.  Williuui  White,  in  Coruil  on  Syphilis.  t  Ibid. 


166  A  TEXT-BOOK   ON   SURGERY. 

the  vessels  in  the  direction  oi'  the  heart.  The  veins  become  swollen,  and 
are  hard  to  the  touch,  resembling  the  normal  veins  when  the  return  cir- 
culation is  momentarily  arrested,  though  more  cord-like  in  h^el  and  less 
elastic.  Their  course  can  be  traced  by  the  dull-red  color  of  tlie  skin 
immediately  over  the  diseased  vessels.  Pain  is  generally  constant,  and 
is  rendered  more  acute  by  pressnre.  The  o'dema  oi  the  ])arts  on  the 
distal  side  of  the  lesion  is  commensurate  with  the  obstruction  to  the 
return  circulation  caused  by  the  inflammatory  process.  The  febrile 
movement  varies  with  the  violence  of  the  attack,  the  rai)idity  of  its 
l)rogress,  the  intensity  of  the  inflammation,  and  the  cajjacity  of  the 
tissues  to  resist  invasion.  In  the  severe  forms,  the  clinical  history  is 
similar  to  that  of  traumatic  phlebitis,  which  will  l)e  fully  desc-ribed 
hereafter.  Idiopathic  phlebitis  is  not  as  dangerous  to  life  as  the  trau- 
matic variety.  It  may  run  a  short  course,  and  the  patient  recover 
promptly,  or  it  may  assume  a  subacute  or  chronic  form,  and  remain 
indefinitely. 

II.  Traumatic  Phlebitis. — When  a  vein  is  injured,  inflammation 
will  result,  if  the  vessel  is  penetrated  to  its  cavity,  or  suffers  a  solution 
of  continuity  in  any  portion  of  its  wall.  Examples  of  traumatic  phlebitis, 
resulting  in  thrombosis  and  occlusion  of  the  popliteal  vein,  are  known 
to  have  been  caused  by  prolonged  forced  flexion  of  the  leg  on  the  thigh. 
The  simplest  form  of  traumatic  phlebitis  is  that  resulting  from  the  opera- 
tion of  venesection.  No  matter  what  may  be  the  character  of  the  trau- 
matism, the  pathological  process  is  the  same.  The  mode  of  termination 
of  this  process  will  depend  upon  the  extent  and  severity  of  the  lesion,  and 
upon  the  recuperative  powers  of  the  tissues  involved.  Traumatic  phlebitis 
extends  from  the  original  lesion  along  the  vessels  in  the  direction  of  the 
heart.  In  the  deeper  veins  it  is  with  difficulty  recognized  in  the  earlier 
stages.  The  course  of  the  inflammation  is  marked  by  a  dull,  coppery-red 
staining.  Pain  is  invariably  present,  and  upon  pressure  is  acute.  In 
severe  cases  the  tumefaction  spreads  from  the  vessels  to  the  suiTounding 
tissues.  Oedema  of  the  parts  on  the  distal  side  of  the  lesion  will  occur  in 
a  degree  commensurate  with  the  interference  with  the  return  circulation. 
The  febrile  movement  is  that  of  septic  fever:  chills  or  rigors,  flushes  of 
heat  ending  in  cold  and  exhausting  sweats,  sleeplessness,  hectic,  anxious 
ex]iression,  and  often  the  "pyjemic  breath."  The  rectal  temperature  is 
variable  and  high ;  the  pulse  is  thready  and  rapid,  reaching  in  some 
instances  160.  Sudden  and  dangerous  symptoms  may  arise  in  the  course 
of  the  disease,  when  particles  from  the  venous  thrombi  are  carried  tcjward 
the  heart.  These  usually  lodge  in  the  lungs,  giving  I'ise  to  sudden  pul- 
monary complications,  the  result  of  infarction.  The  liver,  in  phlebitis  of 
the  veins  which  go  into  the  portal  circulation,  is  frequently  the  seat  of 
embolic  abscess.  Hfemorrhage  from  perforation  of  the  venous  wall,  by 
iilceration  or  gangrene,  is  another  source  of  danger  in  severe  cases  of 
phlebitis. 

Treatment  of  Phlebitis. — Positive  and  complete  rest  is  the  first  great 
essential  in  the  treatment  of  phlebitis.  Manipulation  or  movement  is 
dangerous,  since  interference  wiU  not  only  exaggerate  the  inflammatory 


ARTERITIS.  167 

process,  but  may  possibly  cause  the  separation  of  thrombi  and  produce 
infinite  harm  in  remote  organs.  If  the  disease  should  assume  the  sup- 
})arative  form,  the  inflammation  being  diffuse  and  the  oedema  severe,  free 
incisions  parallel  to  the  veins  should  be  made  in  order  to  secure  drainage. 
A  wet  dressing  should  be  applied,  and  the  wounds  frequently  u-rigated 
with  1  to  10,000  siiblioiate  solution  until  the  more  urgent  sjnnptonis  have 
disappeared.  Quinia  is  indicated,  not  only  on  account  of  its  well-known 
tonic  and  antifebrile  properties — although  not  strictly  antiseptic  in  its 
action,  the  bacteria  of  septic  fluids  resisting  its  action  to  a  great  extent 
(Bartholow) — but  because  it  exercises  an  inhibitory  influence  upon  the 
emigrant  corpuscles  (Binz),  important  factors,  as  Conheim  has  shown,  in 
the  inflammatory  process.  The  use  of  iron,  careful  feeding,  and  a  free 
supply  of  pure  air,  will  complete  the  constitutional  treatment.  If  an 
extremity  is  involved  it  should  be  slightly  elevated  to  favor  the  return 
circulation. 

Arteritis. 

Arteritis  is  a  term  applied  to  an  inflammatory  process  which  involves 
the  entire  thickness  of  the  arterial  wall.  AVhen  the  inflammatory  change 
is  confined  to  the  inner  coat,  or  intima,  it  is  designated  as  endarteritis ; 
when  to  the  outer  coat,  or  adventitia,  as  periarteritis ;  and  v.hen  to  the 
middle  coat,  or  media,  as  mesarteritis. 

Endarteritis,  which  does  not  rapidly  disappear  soon  after  its  inception, 
is  apt  to  result  in  lesions  of  the  media  and  adventitia,  and  in  like  man- 
ner a  lesion  of  the  external  tunic  will  in  all  probability  involve,  by  the 
extension  of  the  morbid  process,  the  other  coats. 

There  are,  however,  certain  well-defined,  circumscribed  lesions  of  the 
separate  tunics.  Endarteritis  is,  as  an  isolated  lesion,  capable  of  demon- 
straticm.  We  shall  see  that  a  supei-ficial  inflammation  of  the  endothelia, 
with  its  resultant  fatty  degeneration,  is  not  infrequent.  Again,  mesar- 
teritis exists  as  a  primary  and  separate  inflammation,  for  primary  calci- 
fication (denied  by  some  pathologists),  which  is  strictly  a  disease  of  the 
tunica  media,  precipitates  an  inflammation  in  this  middle  tunic.  And 
since  atheroma  and  other  arterial  lesions  are  due  to  interference  with  the 
blood-supply  through  the  vasa  vasorum,  or  to  defect  in  the  quality  of 
the  blood  distributed  to  the  adventitia  through  which  the  vessels  ramify, 
we  must  recognize  a  periarteritis  as  the  initial  stage  of  this  lesion. 

Inflammation  may  be  established  in  any  or  all  parts  of  the  arterial 
system.  One  form  of  arteritis  will  involve  the  larger  trunks,  while 
another  will  pass  these  without  molestation,  and  establish  itseK  in  the 
distant  arterioles.  Simple  endarteritis  is  most  apt  to  occur  in  the  aorta 
and  arteries  of  the  second  magnitude,  while  sy|ihilitic  arteritis,  the  most 
marked  feature  of  which  is  an  endarteritis,  rarely  attacks  the  larger 
trunks,  chiefly  confining  itself  to  the  more  or  less  complete  occlusion  of 
the  small  and  smallest  arteries. 

The  internal  coat  of  the  lai'ger  arteries  is  composed  of  two  parts :  1. 
An  endothelial  lining  membrane,  consisting  of  a  single  layer  of  flat,  po- 


168  A  TEXT-BOOK   ON   SURGERY. 

lygonal,  nucleated  cells,  sliyhtiy  elongated  in  the  axis  uf  the  vessel ;  ia 
edge  view,  these  cells  appear  si)indle-shaped,  on  account  of  the  elevation 
of  the  nucleus  at  its  center  Uleif'^niann) ;  2.  A  suliendothelial  layer  of 
flattened,  nucleated,  anastomosing  cells  resting  in  a  Jibrillated  basement 
substance,  the  direction  of  the  fibrilho  being  generally  i)arullel  with  the 
long  axis  of  the  artery  (Cornil  and  Ranvier).  In  the  sm^aller  arteries  this 
layer  is  exceedingly  fine,  while  in  the  aorta  it  is  comparatively  thick, 
being  composed  of  two  distinct  layers.  Here  the  internal  of  these  two 
layers  is  longitudinal,  the  external  transverse  in  direction.  The  middle 
coat  in  the  larger  arteries,  such  as  the  aorta  and  carotids,  is  composed  of 
elastic  laniinjie  and  of  libers,  forming  by  their  anastomoses  a  continuous 
system,  and  holding  in  the  meshes  of  their  loops  the  muscular  tissue, 
transverse  in  its  direction,  and  a  relatively  small  amount  of  connective 
tissue  (Cornil  and  Ranvier).  According  to  C.  ToMt,  the  niiiscle-libers  of 
the  middle  coat  are  wanting  in  the  initial  portion  of  the  aorta,  in  the  pul- 
monary artery,  and  in  the  arterioles  of  the  retina.  In  the  descending 
aorta,  the  common  iliac,  and  the  jjopliteal,  small  bundles  in  an  oblique 
or  longitudinal  direction  are  interspersed  between  the  circular  ones,  and 
in  other  arteries,  such  as  the  renal  and  spermatic,  at  the  inner  boundary 
of  the  muscular  coat,  scanty  longitudinal  bundles  occur,  which  by  some 
are  considered  to  belong  to  the  inner  coat.  At  times,  in  the  correspond- 
ing arteries  of  different  pei'sons,  differences  are  observed  in  the  distribu- 
tion of  the  muscles  of  the  middle  coat  (Heitzmann).  On  the  side  nearest 
the  inner  coat  the  middle  tunic  is  limited  by  a  denser  and  more  defined 
elastic  lamina,  which  shows,  however,  on  transverse  section,  a  festooned 
appearance — very  important  in  the  study  of  the  pathology  of  arteritis — 
and  is  named  the  internal  layer  of  the  elastic  coat.  Upon  the  side  of  the 
tunica  media  nearest  the  external  coat  the  elastic  fibers  pass  outward, 
interlacing,  freely  with  the  connective  tissue  of  the  adventitia.  In  the 
femoral,  brachial,  and  other  arteries  of  middle  size,  the  middle  coat  pos- 
sesses only  one  layer,  namely,  the  internal  elastic.  The  muscular  fibers 
are  transverse  in  direction,  and  form  themselves  into  flattened  bundles, 
separated  by  connective-tissue  bundles  and  by  elastic  fibrillar,  which  are 
continuous  on  the  one  hand  with  the  inner,  elastic  layer,  and  on  the  other 
with  the  elastic  net-work  interwoven  with  the  adventitia.  There  are  no 
vessels  in  the  middle  and  internal  coats.  In  the  external  coat  are  found 
arteries,  capillaries,  vein.s,  lymphatics,  and  nerves. 

The  small  arteries  have  a  middle  coat,  formed  of  involuntary  muscle- 
cells,  so  interwoven  that  they  forai  a  continuous  membrane  (Cornil  and 
Ranvier).  C.  Heitzmann  *  describes  this  layer  as  seemingly  twined  round 
the  artery.  The  adventitia  here  is  composed  of  small  bundles  of  con- 
nective tissue,  arranged  in  the  main  in  a  longitudinal  direction. 

Pathogeny  of  Arteritis. — The  causes  of  arteritis  are  numerous.  The 
most  frequently  recognized  form  is  that  resulting  from  injury,  and  known 
as  traumatic  arteritis.  The  pathogeny  of  the  non-traumatic  {idiopathic) 
arteritis  embraces  every  form  of  dysci-asia.     It  follows  in  the  train  of 

*  "Microscopical  Morphology  of  the  Auimal  Botly  in  Health  and  Disease,"  New  York,  1883. 


ARTERITIS. 


169 


syphilis,  rheiimatism,  gout,  alcoholism,  and  nephritis  with  great  regu- 
larity, and  may  occur  as  a  residt  of  any  morbid  process  which  poisons 
the  blood  or  impairs  its  nutritive  qualities.  These  varieties  will  be  con- 
sidered under  special  headings. 

The  sequelse  of  arteritis,  as  far  as  the  arteries  are  conceraed,  may  be 
fatty  infiltration  and  degeneration,  atheroma,  secondary  calcification, 
occlusion,  dilatation,  aneurism,  suppuration,  ulceration,  and  rupture. 
Remotely,  partial  or  complete  loss  of  function  of  the  organs  beyond  the 
lesion,  and  partial  or  general  necrosis  or  necrobiosis.  I  shall  consider 
arteritis  under  two  great  heads,  traumatic  and  1  ton-traumatic,  subdivid- 
ing these  as  their  pathogeny  or  pathology  may  justify  in  the  considera- 
tion of  each  separate  type. 

I.  Trau.matic  Arteritis. — Arteritis  may  result  from  violence,  either 
from  without  or  from  within.  External  violence  will  produce  an  inflam- 
mation of  all  the  tunics  of  an  artery,  in  the  majority  of  cases,  while  vio- 
lence from  within  is  more  apt  to  cause  an  endarteritis.  Arteritis  from 
external  causes  is  never  an  uncomplicated  injury.  The  perivascular 
tissue  is  of  necessity  involved  in  the  inflammatoiy  process.  In  the  arte- 
ritis resulting  from  deligation  of  an  artery,  from  the  forcible  comjiression 
of  a  vessel,  as  in  bending  the  knee,  from  the  pressure  of  a  tumor,  or  from 
a  blow  in  the  track  of  the  artery,  there  is  always  an  accomj)anpng  inifam- 
mation  of  tlie  surrounding,  injured  tissues. 

The  i^athology  of  traumatic  arteritis  doe.s-not  differ  greatly  from  the  in- 
flammatory process  which 
occurs  in  other  vascular 
tissues.  Immediately  fol- 
lowing the  injury  there  is 
a  marked  increase  in  the 
vascularity  of  the  adven- 
titia.  The  vasa  vasorum 
become  swollen,  the  white 
blood-corpuscles  crowd  in- 
to the  capillaries,  and  pass 
into  the  extra  -  vascular 
spaces,  while  a  rapid  pro- 
liferation of  the  normal 
ceU-elements  of  the  arte- 
rial tunics  takes  place. 
The  connective-tissue  cells 
of  theadventitia,  the  white 
coiiiuscles,  and  the  flat 
and  polar  cells  of  the  in- 
tima,  all  take  part  in  the 
morbid  process.  The  walls 
of  the  vessel  become  ab- 
normally thickened,  while, 
owing  to  the  projection  in- 
wai"d  of  the  intinia,  the 


Fig.  247. — Traumatic  arteritis.  Tiansvei-se  section  of  the  carotid 
artcrj'  ofa  dog,  fifteen  days  alter  lijiuture  :  4,  granulation  buds 
formed  from  iirojoction  of  the  intiraa.  In  the  center  of  the 
figure  one  of  these  buds  has  been  completely  cut  across;  ot, 
portion  of  the  media  modified  by  the  mfljunmatory  process ; 
<".  adventitia;  ('  I',  vessels  cut  acrosSj  one  of  which  is  newlv 
formed  in  the  intima.  Magnified  15  diameters.  ^  After  Cornll 
and  Kanvier.) 


170 


A  TEXT-BOOK   ON   SURGERY. 


N 


r.:^- 


^•T^' 


'"/.'ii'i' 


<M& 


Fio 


caliber  of  tlie  vessel  is  diminished.     If  tlie  intinui  lias  been  broken  or 
bruised  by  tli<>  iiijiiiy,  the  encroachment  upou  tlie  caliber  of  the  vessel 

will  be  more  rapid,  for, 
-  -"-■  -"^"^-'---^  in  addition  to  the  mass 

of  embryonic  tissue 
l)us]iin,<i'  into  the  lumen 
of  the  artery,  there  will 
be  a  deposit  of  fibrin 
upon  the  nnighened 
and  i)rojecting  inter- 
nal tunic.  The  white 
corpuscles  in  the  pass- 
ing blood-current  ad- 
here to  the  inflamed 
surface,  and  undergo  a 
change  whicli  causes  a 
liberation  of  the  iibri- 
no-plastic  matter  which 
they  c^mtain,  and  a 
defiosit  of  librillated 
fibrin.  This  coagulum 
is  found  to  consist  of 
alternate  layers  of  leu- 
cocytes and  fibrin.  In 
the  mean  time,  if  the 
inflammation  be  not  so 
severe  that  rapid  necrosis  occurs  from  the  sudden  arrest  of  the  blood- 
supply  through  the  vasa  vasorum,  new-formed  capillaries  push  through 
the  mass  of  embryonic  cells,  into  the  "granulation  buds"  which  project 
into  the  lumen  of  the  vessel  (Fig.  247). 

This  form  of  arteritis  may  result  in  permanent  occlusion  of  the  vessel 
{endarteritis  obliterans),  or  the  function  of  the  artery  may  be  restored. 
If  occlusion  occurs,  it  results  from  the  organization  of  the  embryonic  cells 
into  a  new  tissue  which  undergoes  fibrillation  and  contraction  (a  process 
of  cicatrization)  to  such  an  extent  that  tire  new-formed  capillaries  are 
more  or  less  occluded,  and  the  artery  shrinks  to  become  a  fibrous  cord 
(Fig.  248).  Or  the  coagulum  may  undergo  fatty  degeneration,  and  be 
swept  away  with  the  current  of  Idood,  the  vessel  remaining  pervious  and 
bearing  but  little  trace  of  the  inflammatory  process  through  which  it  lias 
passed.  The  microscopical  appearances  of  a  localized  traumatic  arteritis 
are  typically  represented  in  Fig.  249.  which  is  copied  from  a  section  made 
from  the  carotid  of  a  horse.  The  animal  was  in  a  healthy  condition  at 
the  time  of  the  operation.  I  tied  the  artery  with  a  broad  carbolized  liga- 
ture, the  sciatic  nerve  of  a  calf.  In  the  fifth  week  the  animal  was  killed. 
The  artery  was  pervious.  The  location  of  the  ligature  was  easily  recog- 
nized by  the  peculiar,  whitish,  pearly  appearance  of  the  intima  at  the 
point  of  tying,  where  it  was  slightly  elevated.  The  adventitia  did  not 
show  any  changes  to  the  naked  eye.     The  ligature  had  evidently  slipped 


248. — Endarteritis  oliliterans,  not  syphilitic.  Ti'ansvei'se  section 
of  the  basilar;  a,  mu-culir  layer;  B,  elastic  layer.  The  lumen  of 
the  artery  is  entirely  tilled  with  a  new  formation,  which  has  become 
canalized  by  new  vessels  at  n  d  f  ;  c,  blood  pigment ;  E,  hyaline 
material,  part  of  the  new  formation  encroaching  on  the  media  at  E, 
and  seen  elsewhere.  (Drawn  liy  Ur.  W.  L.  WardwcU,  from  a  speci- 
men borrowed  from  I'ruf.  \V.  H.  Welch.     Magnified  CO  diametei's.) 


ARTERITIS.  171 

soon  after  the  operation,  probably  witliin  a  few  hours.     The  intima  was 

not  broken,  but  simply  bruised  within  the  gi'a^p  of  the  ligature.     Active 

proliferation  of  the  cells  of  the  intima  had  resulted  from  this  irritation. 

Not  only  is  the  intima  seen  to  bulge  into  the  lumen  of  the  vessel,  but  the 

mass  of  embryonic  tissue  en- 

••rciaches  outward  upon  the 

media,   which   is   thinner  at 

this    point  than   elsewhere. 

At  oue  point  the  media  has 

entirely  disappeared,  leaving 

the  intima  and   externa  in 

actual  contact.     The  adven- 

titia  has  not  undergone  much  -        .-v/^' 

change.      A    few  intiamma-  ^"^-"^fc*^., .  \' 

tory    corpuscles    are    found  iS.      '■•  •'     r'  "^- '  feCS'^^'?^ 

among  the  connective-tissue        d        -■         ■, -^m^^  ^f .  .^-   -,,^ 


C    -r'. 


«^jrvt 


bundles.     If,  after  an  inju-  2z.—      ^"  'Ci  /  '^----■^^^•-■— '--' 

ry  which   induces  arteritis, 

tiie    vessel    be    not    occluded  Fig.  240 -Tnuimatic  endartentL.      Section  from  the  common 

carotid  ot  a  liorse,  tied  with  a  broad  nerve-liiraturc,  sliow- 

throUghout  the  extent  of  the  i"^'  at  bb  the  prolileration  of  the  intima.     The  infiamma- 

,                                    ,     ,  tory  new  formation  is  projected  into  the  lumen  of  the  ves- 

leSlOn,  and    the   injury  or  re-  seljand  has  caused  jiartial  atrophy  of  the  media,  c ;   ab, 

1,.            'a                 I'           \  the  intima;    bb,  portion  of  tlie  intima  in  tlie  ffrasp  of  the 

suiting    intlammation     be    so  ligature;  »,  the  adventitia,  sli^thtlv  chanced,  with  small- 

tsPVPi-Pind  inl-pniP  thnf  Tinirl  "'1'  infiltration.     (Drawn  by  Dr.  W.  L.  "WardwcU,  from 

be\  eie  cUUl  lUUeUSe  lUar  lapia  ji^^  author's  specimen.     Magnified  about  40  diameters.) 

occlusion  of  the  capillaries 

in  the  arterial  wall  takes  place,  suppuration  and  ulceration  of  the  wall 
occur,  with  hjeniorrhage.  Or  septic  matter  may  pass  into  the  vessel 
from  the  surrounding,  inflamed  tissue,  and  lead  to  infarction  and 
pyjemia.  The  same  condition  may  result  from  an  extension  of  in- 
flammation from  the  surrounding  tissues  into  the  arterial  wall,  as  in 
phagedjena. 

Treatment. — No  unvarying  plan  of  treatment  can  be  laid  out  for 
traumatic  arteritis.  The  circumstances  of  each  case  must  be  separately 
considered.  To  prevent  gangrene,  and  to  guard  against  haemorrhage, 
are  the  indications  most  to  be  regarded.  Rest,  position,  quiet,  and  care- 
ful nutrition,  are  the  most  important  points  of  treatment. 

Traumatic  arteritis  resulting  from  causes  within  tlie  vessels  usually 
begins  as  an  endarteritis.  It  may  never  involve  any  other  tunic  than  the 
iutima.  Many  cases  of  acute  traumatic  endarteritis  are  described  as 
idiopathic  inflammations.  They  are  none  the  less  due  to  violence — to 
the  impinging  force  of  the  blood-current ;  for  this  lesion  occurs  at  those 
points  in  the  arterial  system  where  the  pressure  is  greatest.  Endarteritis 
and  the  fatty  degeneration  resulting  from  it  (Figs.  250,  251)  are  most 
frequently  seen  in  the  sinus  magnus  of  the  aorta,  in  the  transverse  seg- 
ment of  the  arch  of  the  aorta,  at  the  aortic  bifurcation  into  the  two 
common  iliacs,  and  in  the  ai<'h  of  the  innominate.  The  arteries  of 
athletes,  which  are  subjected  to  prolonged  distention,  resulting  from 
violent  muscular  exercise,  are  prone  to  sufler  from  thi^  disease. 


i; 


A  TEXT-BOOK   ON  SURGERY. 


Vegetations  from  the  heart  may  produce  endarteritis  when  they  are 
extensive  enough  to  pass  through  the  aortic  valves.  Fragments  from 
whatever  source,  carnVd  along  the  vessels,  produce  arteritis  at  the  jioint 
of  lod-rment. 


Fio.  2fl0. — Arteritis  with  fatty  desencration  of  the 
intima  of  the  aorta.  Tlie  nuclei  of  the  normal 
cells  are  represented  by  the  larirer  bodies,  one 
of  which  IS  seen  at  m  /  tlie  smaller  bodies,  as  at 
^,  are  fatty  granules.  Mairniiicd  400  diameters. 
(From  Cofnil  and  Kanvier.) 


Fig. 


251.— A  form  of  fatty  detreneration  after  arteritis. 
Fatty  de!/eneratir>n  of  the  internal  coat  of  the 
aorta.  Minute  yellowish-white  patches  scattered 
over  the  lining  membrane  of  the  vessel.  A  very 
thin  layer  peeled  off  and  magnified  '200  diameters, 
showing  fat  molecules  and  the  distribution  of  fat 
in  the  intinja.     (From  Green.) 


If  we  examine  the  intima  of  an  artery  which  has  been  the  seat  of 
recent  endarteritis,  it  will  be  seen  to  be  swollen,  and  thicker  and  softer 
than  in  healthy  vessels.  The  swelling  is  not  usually  general  and  con- 
tinuous, but  occurs  in  patches  or  hillocks  of  quite  regular  contour,  which 
project  into  the  lumen  of  the  vessel.  The  intima  is  usually  injected,  and 
reddish  in  color,  though,  according  to  Cornil  and  Eanvier,  when  the  in- 
flammation has  been  of  a  very  severe  type,  the  swollen  intima  is  paler 
than  normal.  If  the  inflammation  be  of  recent  origin,  these  patches  will 
present  an  unbroken  surface  ;  but  if  softening  has  occurred,  the  centers 
of  the  elevations  break  dowTi,  resulting  in  erosions  or  ulcers,  as  they  have 
been  styled  by  some  pathologists.  Green  says  that  they  are  due  to  soft- 
ening of  the  intercellular  substance,  and  that  the  cells  and  granular 
matter,  becoming  loose  from  this  softening,  are  washed  out  by  the  blood- 
current.  These  erosions  resemble  considerably  the  supei-flcial  erosions 
found  often  in  the  mucous  membrane  of  the  stomach.  At  times  they  are 
covered  over  with  a  layer  of  flbrin,  which,  upon  close  inspection,  is  found 
to  be  composed  of  one  or  more  laminje  of  flbrillated  flbrin,  with  corpus- 
cular elements  entangled  in  or  resting  between  them. 

Beneath  the  projecting  intima  is  found  a  mass  of  inflammation-tissue, 
consisting  of  embryonic  and  lai'ge  anastomosing  ceils  resembling  the 
normal  connective-tissue  cells  of  the  most  external  structure  of  the  intima. 
Hyperplasia  of  the  noi-mal  cell-elements  is  more  marked  as  we  approach 
the  inner  layers  of  cells  of  which  the  intima  is  composed,  the  prolifera- 
tion growing  gradually  less  extensive  as  the  elastic  lamina  is  neared. 
This  condition  is  a  feature  of  acute  endarteritis,  and  differs  both  from 
the  inflammation  of  the  atheromatous  process  and  from  syi)hilitic  endar- 
teritis. 

This  mass  of  new-formed  embryonic  tissue  is.  in  all  probability,  the 
immediate  result  of  proliferation  of  the  normal  ceU-elements  of  the  intima. 


ARTERITIS. 


173 


Emigrant  corpuscles  could  only  reach  this  location  by  traversing  the 
media,  for  as  yet  the  capillaries  have  not  been  projected  into  the  inner 
tunic.  Xor  is  it  probable  that  leucocytes,  from  the  blood-current  within 
the  artery  involved,  migrate  through  the  endothelia  into  the  proliferat- 
ing mass. 

The  adventitia  does  not  long  remain  undisturbed  by  the  pathological 
changes  which  have  occurred  in  the  intima.  It  takes  on  an  inflammatory 
process  in  a  varying  degree,  and  this  tunic  is  found  thickened  from  the 
proliferation  of  its  connective-tissue  cells.  If  the  process  be  obstinate 
and  persistent,  a  true  arteritis  is  developed,  and  all  the  jxithological  con- 
ditions which  have  been  described  on  a  previous  page  may  be  present. 

The  media  is  not  greatly  altered  in  the  early  stages  of  endarteritis  or 
periarteritis,  though  in  calcification  it  is  apt  to  be  first  attacked,  as  it  is 
likewise  in  fatty  infiltration  and  degeneration. 

Acute  endarteritis  may  tenninate  in  recovery,  leaving  no  peimanent 
trace  of  its  having  existed,  or  it  may  pass  into  a  chronic  inflammation, 
which  usually  ends  in  fatty  de- 
generation. 

This  degeneration  begins  in 
the  endarteritis  proper,  and  trav- 
els toward  the  media.  The  ap- 
pearances of  an  artery  which  has 
undergone  this  change  are  well 
shown  in  Fig.  252. 

Fatty  degeneration,  in  its  mi- 
croscopic appearances,  resembles 
very  much  the  atheroma  which  is, 
at  times,  found  in  the  intima.  It 
can,  however,  by  gentle  and  care- 
ful scraping,  be  removed,  reveal- 
ing the  more  or  less  normal  tissues 
underneath,  while  in  advanced 
atheroma,  which  involves  the 
deeper  structures  first,  no  trace 
of  the  normal  tissues  can  be  dis- 


^ll///^i'fi!llilliHili'!n  * 


Fig.  252. — Arteritis  with  fatty  dezeneration.  Fiitty  de- 
generation of  the  intenial  coat  of  the  arteries  from 
a  thin  layer  stripped  from  this  membrane,  a,  Fat 
grauules  In  irre^TiIar  patches  over  tlie  surface.  The 
granules  have  resulted  from  fatty  deaeneration  of 
the  cells  of  the  intima.  ^',  Fibrillated  tissue.  Mag- 
nified 200  diameters.     (Comil  and  Kanvier.) 


covered. 

Chronic  arteritis  may  follow  an  acute  endarteritis,  as  has  been  indi- 
cated above,  although  the  chronic  arterial  lesions,  as  a  rule,  begin  with 
perir.rteritis  or  mesarteritis. 

II.  'N'ox-Traumatic  ok  Idiopathic  Arteritis. — The  inflammatory 
process  in  idiopathic  arteritis  dift'ers  only  in  degree  from  that  heretofore 
described  as  occurring  in  traumatic  arteritis.  When  not  due  to  syphilis, 
gout,  rheumatism,  ne]ihritis,  or  some  dyscrasia,  it  is  tisually  a  part  of  an 
inflammation  of  the  tissues  immediately  surrounding  an  arten'.  The 
process  commences  in  the  adventitia,  and  is  analogous  to  that  of  trau- 
matic arteritis. 

Attieroma  and  Calcification. — One  of  the  frequent  and  most  .'serious 
terminations  of  chronic  arteritis,  no  matter  what  may  have  produced  the 


174  A  TEXT-BOOK   ON   SURGERY. 

arterial  lesion,  is  the  condition  known  as  atheromatous  degeneration  (Fig. 
253).  It  is  essentially  a  disease  of  malnutrition.  It  is  a  senile  change, 
not  of  necessity  co-existcut  with  anotiier  disease.  It  is,  as  will  be  proved 
hereafter,  prone  to  attack  the  arteries,  especially  those  of  the  brain,  in 


^<fr 


Fio.  253. — Atheroma  following  arteritis.  Section  of  aorta  under^'niiiL'  tin-  iitluiMmatous  elianjre,  sliowinpr  the 
cellular  infiltration  of  tlic  (lecpcr  layers  of  the  inner  coat,  and  consequent  buljjin^  inward  of  the  intinia. 
The  new  tissue  has  iindcr:,'one  more  or  less  fatty  degeneration.  There  is  some  cellular  infiltration  of  the 
middle  coat,  i,  the  internal ;  ;»,  tlie  middle  :  e,  the  external  tunic.  Ma^'nified  5U  diamuter.s  and  reduced 
one  half.     (Green.) 

syphilis,  and  the  larger  arteries  in  other  affections.  The  fatty  degenera- 
tion of  endarteritis  is  a  primary  lesion,  that  of  chronic  arteritis  is  sec- 
ondary. The  one  is  local,  the  other  general.  Recovery  from  the  one  is 
possible,  and  tlie  danger  of  death  is  .slight.  Shreds  of  fatty  material  may 
be  carried  by  the  blood  and  lodged  in  the  cerebral  or  other  remote  ves- 
sels, doing  great  injury;  but  this  accident  is  rare.  The  possibilities  of 
chronic  arteritis  with  atheroma  are  always  grave.  Above  the  dangers  of 
thrombosis  and  embolism,  and  of  calcification,  are  those  of  aneurism  and 
of  haemorrhage.  The  early  recognition  of  this  condition,  though  exceed- 
ingly difficult,  is  no  less  important.  Atheroma  commences  in  the  deeper 
tissues  of  the  arterial  wall,  and,  advancing  in  the  line  of  blood-supply, 
talis  the  sources  of  nutiition  of  the  deeper  tunics,  causing  their  loss  of 
function,  death,  and  disappearance.     It  is  a  true  necrobiosis. 

The  fatty  degeneration  of  athei-oma  not  only  involves  the  innermost 
layer  of  the  intima  (as  does  that  form  of  degeneration  which  follows 
endarteritis),  but  the  muscular-tiber  cells  undergo  complete  metamor- 
phosis, while  the  elastic  lamina  is  the  seat  of  extensive  infiltration.  In 
severe  cases  the  work  of  destruction  is  complete,  the  normal  tissues  dis- 
appearing, and  leaving  nothing  but  a  granular  debris. 

Atheroma  does  not  usually  destroy  an  extensive  area  of  the  intima. 
The  patches  may  be  numerous,  but  not  large.  The  molecular  disintegra- 
tion is  confined  to  certain  well-defined  spots,  in  the  center  of  which  is 
found  the  softened,  broken-down  *'pulp"  which  has  given  rise  to  the 
term  "atheroma."  Examined  under  the  microscope,  the  contents  of 
these  pulp-cavities  will  be  found  to  consist  of  fat  granules,  granular 
corpuscles,  and  cholesterin  crj^stals,  exactly  analogous  to  those  some- 
times found  in  abscesses  of  long  duration.     Shreds  of  fibrous  tissue  may 


ARTERITIS.  175 

be  present.  It  can  be  readily  conceived  how  the  rupture  of  one  or  more 
of  these  pulp-cavities,  together  with  the  weakened  state  of  the  middle 
and  outer  coats,  would  lead  to  the  formation  of  aneurism.  This  danger 
is  not  so  imminent  when  the  inflammatory  process  has  advanced  slowly, 
for  the  reas(jn  that  secondary  calcification  (a  conservative  process)  is 
more  aj^t  to  take  i)lace.  The  same  may  be  said  of  jnlmary  calcifica- 
tion where  the  lime  salts  are  deposited  in  the  "coagulation  necrosis"  of 
the  media. 

The  atheromatous  and  calcareous  degenerations  may  exist  in  the  same 
location  and  at  the  same  time.  While  the  cell-structure  of  the  intima  is 
being  transformed  into  granular  matter,  the  fibrillated  basement  sub- 
stance nearest  the  media  is  the  seat  of  calcareous  deposit,  at  lii'st  granular, 
the  granules  adhering  to  form  clusters  or  flakes.  At  the  same  time,  the 
nuclei  of  the  muscular-fiber  cells  are  filled  in  and  around  with  calcareous 
matter.  The  entire  muscular  coat  may  be  converted  into  a  calcified 
cylinder,  or,  as  is  most  usual,  the  process  may  be  confined  to  isolated 
patches.  In  either  case,  the  entire  thickness  of  the  wall  may  eventually 
undergo  the  same  morbid  changes. 

When  the  layer  of  cells  between  the  calcareous  deposits  and  the  blood- 
current  has  been  broken  down  by  the  atheromatous  process,  it  may  dis- 
appear in  the  blood  and  leave  the  flakes  of  calcareous  matter  exposed  to 
view  from  within.  These  in  turn  may  be  carried  away,  or  they  may  be 
undermined  by  the  blood-current  and  lead  to  aneurismal  pouches  by 
dissection.  With  atheroma,  calcareous  degeneration  may  invade  the 
entire  arterial  system,  the  arteries  of  the  extremities  becoming  brittle  and 
unyielding.  The  smaller  arteries  are  most  apt  to  be  involved,  especially 
those  of  the  brain. 

In  many  cases  of  atheromatous  and  calcareous  degeneration  in  the 
aged,  enonnous  dilatations  occur.  The  dilatation  is  not  uniform,  as  a 
rule,  but  the  walls  of  the  dilated  artery  (usually  the  aorta  and  the  arte- 
ries of  the  second  class)  are  pouched  in  many  places.  The  calcareous 
matter  will  be  found  to  be  thickest  in  those  portions  of  the  wall  which 
are  less  dilated,  wliile  the  dilated  pouches  have  undergone  a  more  com- 
plete fatty  degeneration. 

This  condition  is  common-      7-__ ==,^^ * 

ly  known  as  arteritis  de-      - 
formans. 

The  middle  coat  may 
be  in  places  entirely  de- 
stroyed, when  the  changed 
intitna  will  be  joined  with 
the  adventitia  by  a  con- 
nective-tissue new-foiTna-  d^^ 
tion,  which  (see  Fig.  247) 

Cnn1-'lin<?vpt!<5pl<5m««iiioTli  F'o..  2.54.-Sbowiiiff  calcareous  deseneration  of  the   media,     a, 

<-<_>niiiiiio  vcaacio^jaosiuf;  Lii-  iiitima;   c c,  media;   d,  adventitia;   bb,  calcareous   patches. 

TPptlv  tn  tViP  intimn        T.r\as  Llnar  arterv.     Magnified  about  60  diameters.     (Kromaspeci- 

tei  uv    lO  I  lie  mrima.      IjOSS  ^^^  prepared  by  Dr.  W.  L.  WardweU.) 

of  the  elastic  tunic  is  one 

of  the  immediate  causes  of  spontaneous  aneurism  (Cornil  and  Ranvier). 


17(3 


A  TEXT-BOOK   ON  SURGERY. 


This  condition  of  atropliy  of  tlie  elastic  lamina  is  well  shown  in  Fig. 

2o4,  which  was  drawn  from  one  of  my  specimens. 

Calcification  of  arteries  has  been  especially  studied  by  Dr.  W.  L. 

^Vard\vell,  of  New  York  city,  in  Conhoim's  Laboratory.     His  experience 

includes  examinations  made 
from  twenty-five  cases  at  the 
request  of  Cdnheini,  who  as- 
sents to  his  conclusions.  Dr. 
Wardwell  says  all  authorities 
recognize  a  inorbid  change  in 
the  arteries  known  as  calcifi- 
catiDn,  and  the  majority  look 
upon  it  as  a  change  second- 
ary to  atheroma  or  endarte- 
ritis. Few  of  these  recognize 
a  primary  calcification  not 
dependent  upon  a  preceding 
infiaramation.  This  condi- 
tion is,    however,    the  chief 


^ilF 


change  in  the  senile  calcifi- 


FiG.  255. — Arteritis  u'itii  ]»rimarv  caleification.  i^ectinn  from 
human  radial  artery,  showing  at  c  primary  calciiieation  of 
the  media,  c.  a,  the  intima  comparatively  unchanged. 
(Drawn  from  specimens  prepared  by  Dr.  \V.  L.  Ward- 
well,  at  Conheim's  Laboratory.  Magnified  about  350 
diameters. ) 


cation  of  arteries.  The  mi- 
croscopic appearances  of  pri- 
mary calcification  are  well 
shown  in  Fig.  235. 

Conheim  states  that  in 
senile  arterial  calcification 
sometimes  the  media,  sometimes  the  interna  (its  outermost  layer),  is 
affected,  and  that  in  them  the  lime  salts  are  deposited.  Moreover,  that 
this  deposit  of  liuie  takes  place  here  because  these  tunics  have  been  sub- 
jected to  the  greatest  strain. 

AVeigert  *  describes  a  "  hitherto  undescribei  "  process  known  as  co- 
acixdaUon.  necrosis.  Beginning  with  the  theory  of  Schmidt  concern- 
ing the  coagulation  of  the  blood,  in  which  the  white  corpiiscles  play  the 
leading  part,  he  argues  that  all  tissues  have  the  power  of  sj^ontaneously 
coagulating,  it  being  necessary  for  such  an  occurrence  that  the  cells 
should  die,  give  up  their  ferment  and  fibrino-plastic  material,  and  then 
becf)me  saturated  with  a  fibrinogen-holding  lymph.  This  morliid  process 
he  holds  may  occur  in  tissues  the  most  diverse  in  character,  as  in  cheesy 
glands,  infarcts  of  the  spleen  or  kidneys,  tumors,  the  inflammatory  ma- 
terial around  parasites,  tubercle,  etc.  Macroscopically,  these  coagulated 
spots  have  a  peculiar,  stiff  appearance,  and,  microscopically,  they  are 
recognized  by  the  fact  that  the  cell  nuclei  have  disappeared,  and  can 
not  be  made  to  appear  by  reagents  or  by  the  material  used  for  staining 
in  microscopical  examination. 

Following  the  line  of  research  indicated  by  Conheim  and  Weigert,  it 
may  be  concluded  :  1.  That  in  the  arteries  of  middle-aged  or  old  persons 


*  Virchow's  "Archiv,"  Bd.  l.";xix,  S.  87. 


ARTERITIS. 


177 


Fig.  256. — Arterites  witli  eoagulation-necrosis.  Section  fiora 
liuiaan  artery  treated  witli  acetic  acid,  showing  at  d  spots 
of  coacrulation-necrosis  which  contained  calcareous  salts 
before  being  trea'ed  with  the  acid  ;  a,  intinia ;  b,  media ; 
c,  adventitia.  (Drawn  from  specimen  prepared  by  Dr. 
W.  L.  Wardwell.    ilaguiticd  about  40  diameters.) 


there  are  often  found  spots  of  diseased  tissiie  which  present  all  the  ap- 
l)earances  of  having  undergone  a  '^  coar/ulation  necrosis.'''' 

2.  That  in  these  spots  there  is  a  tendency  to  the  deposition  of  lime 
salts. 

3.  That  in  primary  calcification  the  media  is  always  first  affected,  the 
intima  and  adventitia  only  secondarily  and  by  contiguity. 

4.  That  this  change  is  in- 
dependent of  a  preceding  in- 
ilammation. 

5.  That,  on  the  contrary, 
these  calcitied  spots  act  as 
foreign  bodies,  setting  up  a 
secondary  inflammation  in 
theii-  vicinity,  and  leading 
sometimes  to  thickening  of 
the  intima. 

C).  That  one  of  the  changes 

in  atheroma  of  the  arteries 

is  coagulation-necrosis,  that 

lime  salts  are  often  deposited 

in  siach  necrotic  spots,  that 

the  position  of  such  spots  is  in  the  intima  instead  of  the  media,  viz.,  in 

the  newly  formed  inflammatory  tissue. 

7.  That  primary  calcihcation  attacks  the  small  arteries  rather  than 

the  larger,  and  especially  those  portions  of  the  arteries  which  are  subject- 
ed to  the  greatest  strain.* 
These  conditions  are 
shown  in  Figs.  256  and 
237. 

Sy2)hilitic  Arteritis. 
— Arteritis  is  a  part  of 
the  pathology  of  syjihilis. 
The  first  danger  to  life  in 
this  disease  comes  from 
the  changes  in  the  ca- 
pacity of  the  arteries. 
No  part  of  the  arterial 
system  is  exempt,  though 
the  most  serious  lesions 
are  found  in  the  vessels 
of  the  brain,  and  next  in 
the  aorta.  They  become 
grave  in  the  larger  trunks 

R     o^-    D   .  ■    .u-  ,  -.        o    ■      u    •  ,  .■  on  account  of  the  athero- 

riG.  a5i. — rostcnor  tibial  artery.    Section  showing  coagulation-ne- 
crosis.   A,  intima;   b,  media;   c.  adventitia;   »,  spot  of  eoagu-  ma     resulting     from     the 
lation- necrosis.     Magnitiod  300  diameters.     (From  a  specimen  -,....  \  /•      -i 
preparedby  Dr.  W.L.  Wardwell.)  SyplulltlC   pOlSOn    (induc- 


*  For  tbese  conclusions  the  author  is  iudebted  to  Dr.  W.  L.  Wardwell. 
13 


178 


A  TEXT-BOOK  ON  SURGERY. 


iiig  iim-iirism),  and  in  the  smaller  arteries  (especially  those  of  the  braiu) 
from  occlusion  or  atheroma. 

Even  in  the  initial  lesion  of  syphilis  (the  chancre),  accord in'j;  to 
Biesiade(d\.i,  the  capillaries  of  the  papilhe  have  in  their  thickened  walls 
many  nuclei,  some  of  which  are  seen  to  project  into  the  lumen  of  the 
vessel. 

The  arteries  of  the  baae  of  the  brain,  especial)}'  the  basilar  and  those 
at  the  commencement  of  the  fissure  of  Sylvius,  are  often  seriously  in- 
volved. I  have  seen  two  cases  in  private  practice  in  which  death  lesulted 
from  anjemia  of  the  medulla,  due  to  a  more  or  less  complete  thrombosis 
of  the  basilar  artery.  A  jjatient  of  Dr.  Weber's,  to  whom  I  was  called, 
died  in  my  jiresence.  A  few  days  previous  to  his  death  he  had  com- 
plained of  dizziness,  and  of  a  sensation  as  of  insects  crawling  over  the 
integument  of  the  extremities.  Death  was  quite  sudden,  and  was  due 
to  respiratory  failure.  He  became  quickly  unconscious,  the  respiratory 
movements  were  irregular,  and  co-ordination  of  movement  between  the 
expiratory  and  inspiratory  muscles  was  seemingly  lost.  The  mode  of 
death  was  different  from  anything  I  had  ever  witnessed.  At  the  autopsy, 
the  basilar,  just  where  it  divided  into  the  two  posterior  cerebrals,  was 
found  almost  completely  occluded  by  a  thrombus.  There  was  no  other 
lesion  which  could  have  accounted  for  death.  Syphilis  had  existed  for 
several  years. 

In  the  second  case  syphilis  had  existed  for  nineteen  years,  with  right 
hemiplegia  for  the  last  sixteen  years  of  life.     This  patient  was  under  my 

care  for  nearly  five  years. 
She  would  never  consent 
to  take  the  iodides  or  any 
medicine.  Her  mind  was 
clear  up  to  the  time  I 
last  saw  her  before  death, 
which  occurred  suddenly 
one  night.  I  did  not  see 
her  until  life  was  extinct, 
l)ut,  from  the  description 
of  the  mode  of  death  given 
me  by  Dr.  F.  J.  Ives,  who 
was  present,  I  was  led  to 
express  the  belief  that  a 
similar  condition  existed  as 
in  the  case  first  referred  to. 
On  examination,  I  found  a 
thrombosis  of  the  basilar 
artery  in  exactly  the  same 
location.  Fig.  258  repre- 
sents a  section  of  the  artery 
near  the  thrombus.  The  lumen  of  the  vessel  is  seen  to  be  about  two  thirds 
occluded.  The  adventitia  is  slightly  thickened,  and  the  cell-elements  in 
it  are  distinctly  fusiform,  and  regularly  parallel  with  each  other  and  with 


B  — 


Fig  258. — Svpl)ilitic  arteritis.  Section  of  basilar;  i;,  lumen  of 
ve.*sel  about  two  tliirils  filled  witli  new  tbrmation  at  ab; 
c,  media  ;  d,  muscular  layer  and  adventitia.  From  a  patient 
dead  i'rom  syphilis.  (Specimen  of  the  author's,  drawn  by 
Dr.  Wardwell.     Magnified  about  40  diameters.) 


ARTERITIS.  179 

the  contour  of  the  adventitia.  The  wavy  elastic  layer  is  easily  recognized, 
and  in  that  portion  of  the  artery  in  which  the  sypliilitic  intiammatory 
material  is  deposited  the  waves  of  the  media  are  more  numerous  and 
shorter  than  in  other  portions  of  the  vessel.  In  the  center  of  the  mass, 
occupying  a  portion  of  the  caliber  of  the  artery,  is  found  a  hyaline-look- 
ing spot  which  took  the  carmine  stain  more  readily  than  the  general  mass 
of  the  thrombus.  It  contains  embryonic  cells  in  about  the  same  quantity 
as  the  surrounding  tissue.  The  adventitia  is  not  regularly  thickened, 
being  three  or  four  times  as  deej:)  in  some  portions  as  in  others,  and  pre- 
senting in  the  section  a  nodulated  appearance.  Viewed  with  a  magnify- 
ing power  of  about  five  hundred  diameters,  that  portion  of  the  arterial 
wall  external  to  the  wavy  line  (the  elastic  layer),  seen  in  Fig.  258,  presents 
the  following  appearance : 

In  the  most  external  limit  of  the  section  of  the  adventitia  there  are 
found  clusters  of  iniiammatory  corpuscles,  true  embryonic  cells,  round, 
and  larger  than  the  cells  found  in  any  other  portion  of  the  sj^eciraen 
external  to  the  elastic  lamina.  These  cells  are  somewhat  smaller  in  size 
than  those  found  in  the  new-formed  tissue  of  the  intima,  though  they 
differ  in  shape,  since  those  in  the  intima  appear  both  round  and  fusiform, 
while  the  cells  in  the  outer  edge  of  the  externa  apj^ear  almost  invariably 
round.  It  may  be  possible  that  they  are  fusiform  cells  cut  transversely 
in  thtt  section ;  though  after  careful  examination  I  am  led  to  conclude  that 
they  are  round.  At  various  points  tliese  cells  do  not  exist,  the  external 
layer  being  that  of  fusiform  cells  arranged  with  great  regularity  parallel 
to  the  contour  of  the  wall  of  the  artery.  AVhere  the  wall  of  the  vessel 
external  to  the  elastic  lamina  is  thickest,  these  spindle  cells  are  more 
numerous,  and  have  a  greater  transverse  diameter  than  at  the  narrower 
portions,  where  they  seem  to  have  elongated  and  become  thinner — seem- 
ingly a  true  process  of  fibrillation  and  contraction  of  embryonic  (inflam- 
matory) cells. 

Continuing  the  examination  farther  inward,  as  the  white,  wavy, 
elastic  zone  is  crossed.  Just  within  and  almost  in  exact  apposition 
with  this  is  a  somewhat  irregular  and  thin  layer  of  cells,  fusiform 
in  section,  varying  in  de]ith  from  a  single  row  to  two  or  three  rows, 
and  in  some  points  entirely  absent.  These  are  doubtless  a  remnant 
of  the  original  endothelia  of  the  intima ;  just  internal  to  these,  and  in 
fact  continuous  with  them,  is  the  great  mass  of  new-formed,  inflamma- 
tory tissue  which  juts  into  the  lumen  of  the  vessel.  This  mass  is  com- 
jiosed  of  large,  mostlj^  fusiform,  cells,  distinctly  nucleated  and  occupy- 
ing about  as  much  space  as  the  intercellular  substance  in  which  they  are 
imbedded. 

Syphilitic  arteritis  has  been  made  the  subject  of  special  study  by 
Cornil,  Heubner,  Greenfield,  Barlow,  Buzzard,  Davidson,  Simes,  White, 
and  others. 

Greenfield,  in  the  "  Transactions  of  the  London  Pathological  Society 
for  1877,"  gives  an  analysis  of  22  cases  of  visceral  syphilis. 

Of  the  22  patients,  13  were  females,  9  males.  Their  ages  varied  from 
23  to  50  years.     Of  the  females,  4  were  between  the  ages  of  23  and  25,  1 


180  A  TEXT-BOOK   OX   SURGERY. 

was  35,  1  was  38,  the  remainder  between  40  and  50.  Of  the  males,  4  were 
between  30  and  40,  the  rest  between  40  and  50. 

These  jiatients  did  not  all  die  from  syphilis,  some  perishing  from  f)ther 
and  concoiuitant  diseases.  Of  those  who  died  from  the  effects  of  syphilis, 
the  greater  number  were  comparatively  young.  Of  the  four  females 
under  twenty-hve  years  of  age,  two  died  from  the  effects  of  thi-ombosis 
of  the  cerebral  arteries,  one  from  syphilitic  disease  of  the  larynx,  and 
one  from  accident.  Of  the  six  males  under  forty,  one  died  from  sj^phi- 
litic  disease  of  the  cerebral  arteries,  one  from  gummata  of  the  l)i:iiii  and 
dura  mater,  one  from  pneumonia  due  to  sj-philitic  disease  of  the  larynx 
and  trachea,  one'  from  renal  disease  consequent  upon  stricture,  and 
another  by  accident. 

In  the  total  of  twenty-two  cases,  the  condition  of  the  vascular  system 
was  noted  in  aU  but  six.  In  one  case  there  was  no  lesion  of  the  arteries. 
In  the  remaining  fifteen  cases  the  arteries  were  more  or  less  seriously 
involved.  In  other  words,  out  of  sixteen  cases  in  which  the  condition  of 
the  arteries  was  noted,  in  fifteen  these  vessels  were  diseased. 

The  author  says  that  the  condition  of  the  aorta  and  large  vessels,  as 
regards  atheroma,  is  of  importance  in  connection  with  the  dependence  of 
aneurism  upon  syphilis,  and  that,  as  regards  the  smaller  vessels,  the 
nature  of  the  disease  of  the  cerebral  arteries  is  of  the  greatest  interest. 
In  three  females,  aged  twenty-three,  twenty-five,  and  twenty-five,  there 
was  marked  atheroma  of  the  aorta.  In  one,  the  atheroma  was  general 
in  the  aorta  and  its  larger  branches,  the  condition  being  that  of  diffused, 
irregular  swelling,  with  but  little  fatty  degeneration.  In  one  female, 
aged  twenty-five,  in  the  first  part  of  the  arch  of  the  aorta  were  several 
patches,  rounded,  prominent  in  the  center,  and  thicker  than  usual.  On 
section  these  appeared  homogeneous,  and  presented  scarcely  any  fatty 
degeneration.  Throughout  the  rest  of  the  aorta  there  Avas  geneiTil  athe- 
roma, with  no  peculiar  characters.  In  another  female,  aged  thirty-five, 
there  were  large  patches  of  endarteritis  defonnans  in  the  alxlominal  aorta. 

In  several  other  cases  there  was  marked  atheroma,  and  in  most  cases 
where  there  was  no  renal  disease  the  patches  were  much  raised,  some- 
times almost  hemispherical,  at  other  times  with  sharply  defined  edges  of 
gelatinous  appearance  and  pearly  luster ;  and  on  section  there  was  but 
little  fatty  degeneration  or  calcification. 

Whether  in  these  cases  the  disease  would  have  gone  on  to  the  forma- 
tion of  aneurism,  can  not  of  course  be  decided ;  but  it  is  evident  that  a 
marked  tendency  to  the  occurrence  of  endarteritis  deformans  at  an  early 
age,  and  in  an  advanced  degree,  exists  in  visceral  syphilis. 

The  cerebral  arteries  were  very  markedly  affected  with  syphilitic  dis- 
ease in  five  cases,  and  in  a  sixth  were  probably  diseased. 

As  to  the  pathological  changes  which  syphilitic  arteritis  causes,  they 
are  given  by  Dr.  Greenfield  in  two  cases  of  disease  of  the  cerebral  arteries. 

The  specimens  were  taken  from  the  middle  cerebral  and  basilar  arte- 
ries. They  are  typical,  and  probably  represent  two  different  stages  of  the 
process.  In  the  first  case  the  disease  is  seen  in  the  earlier  form,  in 
which  it  consists  almost  entu-ely  of  a  cell-growth  which  has  as  yet  under- 


ARTERITIS. 


181 


gone  but  little  organization.  In  the  second  case  considerable  changes 
liave  occuiTed,  and  a  large  part  of  the  new  growth  is  converted  into  more 
or  less  fuUy  developed  connective  tissue.  In  the  specimen  sketched  in 
Fig.  2o9,  the  artery  is  seen  to  be  somewhat  irregular  in  shape,  this  being 
due  to  obliquity  of  the  section.  The  lumen  (a)  is  very  small,  but  is  clearly 
defined,  rounded,  and  free  from  throml)us. 

The  outer  coat  appears  somewhat  thickened,  and  is  infiltrated  in  con- 
tinuity with  the  pia  mater  (/).  The  muscular  coat  (d)  is  distinctly  seen 
at  the  upper  and  lower  parts  of  the  section,  elsewhere  being  somewhat 
infiltrated,  and  not  clearly  separated  from  the  adventitia.  The  fenestrated 
membrane  is  clearly  seen  at  b,  where  it  is  indicated  by  the  dark  lines  ;  it 
could  be  clearly  ti'aced,  on  altering  the  focus,  all  around  the  vessel,  lying 
as  usual  immediately  internal  to  the  muscular  layers,  and  separating 
them  from  the  inner  coat.  It  is  to  that  part  of  the  vessel  lying  between 
a  and  b  (Fig.  2.-)9)  that  attention  must  be  specially  directed,  the  thickened 
inner  coat  constituting  the  essential  feature  and  the  peculiarly  character- 
istic element  of  the  morbid  change.  With  a  higher  powei",  the  thicken- 
ing of  the  inner  coat  is  seen  to  consist  entirely  of  a  cell-growth  which 
closely  resemldes  granulation-tissue.  In  the  deeper  parts,  nearest  the 
fenestrated  membrane,  the  cells  appear  to  be  flattened,  running  parallel 
with  the  elastic  layer,  growing,  however,  more  irregular  in  disposition 
toward  the  center.  No  distinct  transition-line  can  be  discovered  between 
this  deeper  layer  and  the  central  part,  in  which,  however,  the  cells  appear 
to  be  larger,  often  branching  and  more  loosely  ari-anged,  with  more 
numerous  capillaries  running  among  them.  Many  of  the  cells  in  the 
intermediate  layer  ap^jear  to  be  rounded  ;  but  it  is  not  improbable  that 


Flo.  259. — Sypliilitie  iirterilis.  Shows  sec- 
tion of  smiiU  cerebral  :irtiTy  near  a  gum- 
ma, matrniSed  30  dianKtcrs.  a,  lumen 
of  vessel;  li,  boundary  of  iiuier  middle 
coats;  c,  thickened  inner  coat ;  </,  mid- 
dle coat ;  e,  external  coat ;  f.  infiltrated 
pia  mater.    (After  Greenfield. ) 


.■^' 


Sy  V 


Fia.  2flO. — Syphilitic  arteritis.  Section  of  small  artery 
of  cerebellum,  mai/nified  30  diameters.  «,  lumen 
of  vessel ;  c,  thickened  inner  coat ;  </,  muscular 
coat;  f,  outer  coat.     (After  Greenfield.) 


they  are  fusiform  cells  cut  transversely.     In  many  parts  of  the  thickened 
iutima  the  capillaries  are  numerous  and  of  large  size. 

Toward  the  lumen  of  the  vessel  the  cells  again  assume  a  flattened  or 


182  A  TEXT-BOOK   ON  SURGERY. 

fusiform  shape,  and  several  layers  of  these  cells  closely  packed  topjether 
form  the  innermost  part  of  the  new  growth,  tlie  most  internal,  super- 
ficial layer  (that  in  immediate  contact  with  the  blood-current)  forming 
a  ccmtinuous  layer,  which  corresponds  in  its  functions  to  normal  endo- 
thelium. 

The  other  specimen  (Fig.  260)  appears  to  have  undergone  different 
changes.  The  coats  of  the  vessel  are  enormously  thickened,  and  the 
lumen  of  the  vessel  correspondingly  diminished,  so  as  to  become  a  nar- 
row chink  (the  section  is  somewhat  obliquely  made).  The  thickening  of 
the  wall  is  found  to  i:)resent  great  variations,  at  points  of  the  vessel  not 
farther  apart  than  one  twelfth  of  an  inch,  other  sections  at  that  distance 
from  the  one  represented  in  the  cut  not  being  more  than  one  half  as 
thick,  the  external  diameter  of  the  vessel  remaining  almost  constant. 
The  adventitia  {e)  is  slightly  thickened  and  infiltrated  by  a  cell-growth. 
The  muscular  coat  (r7)  is  of  pretty  uniform  thickness,  except  at  some 
points  where  invaded  with  cell-intiltration  from  the  adventitia.  The 
inner  coat  is  enormously  thickened,  and  presents  the  appearance  of  two 
concentric  rings,  the  boundaiy  between  which  is  more  or  less  defined. 
Examined  with  a  higher  power  (Fig.  261),  the  lumen  of  the  vessel  is 


■^mr0^l 


f    • 


':Tu::v^:^^, ■         -'-i  '''mms-^^^^>M:v::/:^'-'''''  -'^ ,^l. 


e 

Fig.  261. — Syphilitic  arteritis.     Segment  of  the  precedin?  specimen,  mafrnified  170  diameters,     a,  lumen  of 
vessel:   6,  fenestrated  membrane;   a,  f,  thickened  i    ' 
formed  imperfect  elastic  lamina.     (Alter  Greenfield.) 


!rs. 

vessel:   6,  fenestrated  membrane;   a,  f,  thickened  intinia;   </,  muscular  coat;   v,  adventitia;   g,  new- 
med  imperfect  elastic  lamina.     (Alter  Greenfield.) 


found  free  from  thrombus.  The  membi'ana  fenestrata  is  well  defined. 
The  muscular  layer  presents  very  much  its  normal  appearance  at  some 
points,  except  that  the  fiber-cells  are  somewhat  granular.  At  some  points 
it  is  encroached  upon  by  the  cell-growth  from  the  outer  coat,  between 
which  and  the  muscular  coat  there  is  no  distinct  line  of  demarkation. 
The  outer  coat  is  somewhat  irregularly  thickened  by  cell-growth,  which 
is  especially  abundant  around  the  vasa  vasorum,  which  are  very  numer- 
ous and  much  more  developed  than  usual.  At  some  points  small  vessels 
traverse  the  muscular  and  elastic  coats,  going  into  the  deeper  portions  of 
the  thickened  intima. 

The  inner  coat  measures  t\\-ice  the  thickness  of  the  outer  and  middle 


ARTERITIS. 


183 


coats  together.  Starting  from  the  fenestrated  membrane,  in  its  neigh- 
borhood there  is  found  a  rather  abundant  oell-growtli  traversed  by  capil- 
laries. Nearer  tlie  intima  is  found  a  tibrous  tissue,  formed  of  elongated, 
fusiform  cells  and  delicate,  interlacing  iibrils  of  connective  tissue,  the 
whole  constituting  an  imperfectly  developed  fibrous  tissue.  Internal  to 
this  are  seen  more  numerous,  rounded  cells,  some  of  which  are  of  larger 
size.  Nearer  to  the  lumen  are  seen  elongated,  oval  nuclei,  smaller  and 
more  highly  refractile,  and  more  closely  packed  together  (Greenfield). 
It  will  be  seen,  by  reference  to  my  own  case  already  given,  that  in  the 
changes  which  occurred  in  the  intima  it  was  analogous  to  Dr.  Greenfield's 
first  case,  while  in  the  irregular,  nodulated  condition  of  the  muscular 
layer  it  was  analogous  to  his  second. 

According  to  Greenfield,  the  inflammatory  matter  in  and  around  the 
perivascular  canals  in  syphilis  is  entirely  different  from  that  in  tuber- 
cular infiltration  of  these  canals. 

In  vessels  examined  by  Barlow,  the  same  changes  are  reported  as 
those  given  above  (Figs.  262,  263).     The  adventitia  and  muscular  coats 


Fig.  2R9. — Syphilitic  arteritis.  Transverse  section  of 
a  se^tiK'iit  of  tlie  middle  coret)ral  artery  of  a 
sypliilitic  iiatient.  i,  the  thiekeiied  intiina;  e, 
tile  endotlielium;  /,  tiie  fenestrated  membrane; 
m,  tlie  muscular  coat ;  (7,  the  adventitia.  (From 
Barlow's  Specimens,  Green's  *'  Pathology.") 


Flo.  263.— Syphilitic  arteritis.  Section  from  a 
small  art«ry  of  the  pia  inatcr  cut  trans- 
versely, showintr  the  inner  coat  mucii  thick- 
ened, a  diminution  of  the  lumen  of  the 
vessel,  and  a  considerable  infiltration  of 
the  adventitia.  A  clot  is  seen  to  occupy 
a  great  part  of  the  lumen  of  the  vessel. 
(From  Barlow's  Specimens,  Green's  "Pa- 
thology.") 


were  more  or  less  affected,  "but  obviously  the  principal  changes  have 
taken  j^lace  in  the  intima."  Davidson  and  Buzzard  are  led  to  the  same 
conclusions  with  the  foregoing,  as  is  Green  in  his  "Pathology  and  Mor- 
bid Anatomy." 

Rhmnnatic  Arteritis. — Arteritis  may  occur  in  connection  with  acute 
rheumatism.  Bryant  states  that  this  is  a  rare  form  of  disease.  Rheu- 
matic endocarditis  is  not  so  rare,  and  it  is  possible  that  endarteritis  may 
exist  in  the  aorta  in  many  cases  of  endocarditis.  This  and  the  arteritis 
of  gout  and  nephritis  (Fig.  264)  belong  to  the  domain  of  medicine  rather 
than  to  that  of  surgery,  and  will  not  therefore  be  considered  in  this  work. 


184 


A  TEXT-BOOK  ON  SURGERY. 


_-<y 


y ^  ^ 


'^ 


^^-^^^^-^ 


■</' 


The  treatment  of  arteritis  resolves  itself  simply  into  the  treatment  of 
the  disease  of  which  it  is  a  part.     It  would  be  useless  to  increase  the 

length  of  this  article  by  a  re- 
capitulation of  the  various 
methods  and  remedies  which 
have  been  employed.  If  the 
]iathogeny  and  pathology  of 
rhi>  att'ecrion  are  understood, 
its  therapy  is  not  difficult. 

Arterial  T]iroinJ>osis  and 
Entbolisiu, — Though  not  as 
fiequentasin  phlebitis,  throm- 
bosis and  embolism  often  I'e- 
sult  from  arteritis.  The  pa- 
thology of  thrombosis  has  been 
given  in  the  section  on  phlebi- 
tis. The  ])rocess  in  the  arteries 
is  closely  analogous  to  that  in 
the  veins. 

The  perfect  type  of  throm- 
bosis   from    acute,    traumatic 
arteritis,  is  found  after  the  application  of  an  occluding  ligature  around 
an  artery. 

By  reason  of  arrest  of  the  blood-current  and  disturbance  of  the  equi- 
librium normally  existing  between  the  blood  and  the  containing  vessels, 
coagulation  takes  place  on  the  cardiac  side  of  the  ligature,  extending 
back  as  a  rule  to  the  first  collateral  branch.  Immediately  following  the 
injury  to  the  vessel,  the  process  of  infiamniation — true  arteritis — com- 
mences.    The  tension  of  the  ligature  to  such  a  degree  as  to  divide  the 


rniiic  nejMintis.  Section  trnm 
posterior  tiltial  artery  o!' patient  aead  Irom  lirij^lit's  dis- 
ease, showing;  at  a  L^reat  tbiekeuing  of  the  intiiiia.  the 
result  of  eiironic  endarteritis.  The  elastic  lamina,  i>, 
nnphanijed.  The  inuseular  layer,  b,  slightly  thicUened. 
r,  a<l\ent!tia  greatly  thickeneil  at  places  by  small-cell 
infiltration.  Drav.u  from  specimens  prepared  by  Dr. 
W.  L.  Wardwcll,  at  Conhcnn's  Laboratory.  (Magni- 
fied about  40  diameters,  i 


Fio.  265.— Longitudinal  section  of  the  artery  of  a  dog  fifty  days  afler  the  ligature.     Clot  injected.    Magnified 

40  diameters.     (After  ().  Weber.) 

inner  or  middle  coat,  or  both,  is  unnecessary.     I  have  tied  arteries  (carotid 
and  subclavian)  in  human  beings,  and  in  horses  and  dogs,  and  have  speci- 


ARTERITIS. 


185 


mens  which  demonstrate  successful  occlusion  of  the  vessel  without  divis 
ion  of  either  of  the  three  tunics.  Scarpa  advanced  this  idea  years  ago, 
but  surgeons  generally  have  decried  it. 

The  coagulation  thrombus  disapj^ears  by  fatty  degeneration.  The 
pei-manent  occlusion  is  due  to  new-formed  tissue  springing  from  the 
normal  cells  of  the  intima  and  the  leucocytes.  O.  Weber  held  that  the 
clot  became  organized  into  a  true  tissue,  into  which  blood-vessels  were 
projected  from  the  vasa  vasorum  (Fig.  265).  But  Cornil  and  Ranvier 
long  since  disproved  this  assertion  of  Weber.  BubnoiT  held  that  the 
white  blood-corpuscles  emigrated  through  the  walls  of  the  ligatured  ves- 
sel, permeated  the  clot,  and  caused  its  organization  ;  but  Durante  (Cornil 
and  Ranvier)  has  demonstrated  that  the  leucocytes  only  traverse  the  walls 
of  the  vessel  when  this  has  been  tied  with  a  double  ligature,  causing  a 
death  of  the  included  vessel,  and  that  the  leucocytes  travel  through  this 
dead  tissue.  They  do  not  permeate  the  walls  of  an  otherwise  healthy 
artery  which  has  been  tied  witli  a  single  ligature. 

Cell-proliferation  takes  place  rapidly  in  the  intima  ;  granulation-buds 
project  into  the  territorj^  occupied  by  the  clot  (Fig.  266) ;  blood-vessels 
derived  from  the  vasa  vasorum 
permeate  the  projecting  granu- 
lation-tissue, invade  the  clot, 
meet  with  live  vessels  from  the 
opposite  side,  and  join  with 
these  in  a  continuous  circu- 
lation ;  the  embryonic  tissue 
organizes,  gradually  contracts 
(process  of  cicatrization),  and 
the  walls  of  the  vessel  are  per- 
manently occluded  by  this  fibril- 
lation. Afterward  the  new- 
formed  vessels  disappear  to  a 
great  degree,  being  obliterated 
by  the  process  of  contraction. 

Fig.  249,  from  a  section  of 
the  carotid  of  a  horse,  shows 
how  this  rapid  proliferation  of 
the  nonnal  cells  of  the  intima 
occurs  when  the  intima  has  not 
been  divided.  Thei'e  was  in 
tills  case  simply  an  irritation 
of  the  intima,  a  bruising,  the 
result  of  jamming  together  the  opposing  surfaces  of  the  intima  bj'  means 
of  a  broad  (not  cutting)  ligature. 

Thrombosis  from  acute  arteritis  is  rare.  Chronic  arteritis  is  not  in- 
frequently the  cause  of  occlusion.  Syphilitic  arteritis  is  apt  to  develop 
thrombosis  of  the  cerebral  arteries.  Arterial  thrombosis  (excluding  the 
vessels  to  the  l)rain  and  walls  of  the  heart)  is  not  as  dangerous  to  life  as 
venous  thrombosis. 


Fig.  2<ir..— Traumatic  endarteritis.  Transverse  seetion  ot 
the  tcninrul  artery  of  a  dog  eis;lit  days  after  the  appli- 
eatinn  of  a  ligature,  t;  the  elf..stic  lamina  ;  /),  the  me- 
dia; A,  granulation-bud  prqieeting  from  tne  intima 
into  the  lumen  ;  t\  new-formed  vessel  running  through 
tlie  intlanunatory  tissue.  At  a  the  elastic  layer  lias 
partly  disappeared.  Magnified  30  diametei-s.  "  (From 
Corud  and  Kanvier. ) 


186  A  TEXT-BOOK   ON  SURGERY. 

The  process  is  usually  so  gradual  that  the  collateral  circulation  is 
established  before  occlusion  of  the  main  trunk  occurs.  This  may,  in- 
deed, escape  observation  until  the  enlarging  superlicial  arteries  attract 
attention. 

The  thrombus  formed  under  such  conditions  differs  from  the  organized 
thrombus  at  the  seat  of  a  ligature,  inasmuch  as  the  passing  blood-current 
furnishes  fibrin-making  white  corpuscles  with  accom])anying  fibrin-deposit 
in  the  (me,  while  this  can  not  occur  after  a  ligature  is  apjylied. 

The  causes  of  thrombosis  may  be  summed  up  as  follows  :  1.  Occlusion 
of  the  vessel  as  by  a  ligature.  2.  Inflammation  of  the  intima  (arteritis). 
3.  Dilatation  of  the  vessels  (as  in  aneurism).  4.  An  abnormal  condition 
of  the  blood.  5.  Heart  failure.  6.  Narrowing  of  the  caliber  of  an  artery 
by  pressure. 

Vascular  Tumors. 

We  may  recognize  six  varieties  of  vascular  tumor,  apart  from  true 
aneurism.  These  are :  1.  Arterial  varix  ;  2.  Cirsoid  arterial  tumor,  or 
cirsoid  aneurism ;  3.  Arterial  cutaneous  tumor ;  4.  Capillary  cutaneous 
tumor ;  5.  Venous  cutaneous  tumor  (these  three  varieties  are  usually 
classed  together  under  the  name  of  angeiomata) ;  and  6.  Venous  varix, 
or  simply  varix  (varicose  vein). 

Arterial  Varix  may  be  defined  as  a  dilatation  and  elongation  of  an 
artery  of  the  second  magnitude  (as  the  external  iliac  or  common  carotid), 
of  the  third  (as  the  external  carotid  or  posterior  tibial),  or  of  the  fourth 
(as  the  temporal,  facial,  superior  thyroid,  or  palmar  branches  of  the  radial 
and  idnar).  Cruveilhier  has  reported  a  case  of  arterial  varix  of  the 
external  iliac  artery.  I  have  made  one  dissection  of  arterial  varix  of  the 
superior  thyroid  artery,  in  which  this  vessel  was  greatly  elongated,  and 
as  large  as  the  external  or  internal  carotid.  It  was  tortuous,  but  not 
sacculated,  the  dilatation  being  general.  Tillaux*  reports  a  case  of 
cirsoid  anetirism  of  the  hand,  with  dilatation  of  the  arteries  of  the  fore- 
arm and  humeral  region. 

Treatment. — Arterial  varix  may  be  treated  by  compression,  or  by  the 
ligature,  when  such  a  procedure  becomes  necessary.  In  a  case  which  I 
saw  after  the  patient's  death,  and  in  which  the  su])erior  thyroid  artery 
Avas  involved,  the  ligature  would  have  been  advisable.  The  artery  was 
in  a  healthy  condition,  with  the  exception  of  its  increased  length  and 
caliber. 

When  connected  with  cirsoid  arterial  tumors^  the  solidification  of 
these  by  ligature,  cautery,  or  injection,  will  iisually  cure  or  palliate  the 
arterial  varix. 

Cirsoid  Arterial  Tumor,  or  Cirsoid  Aneurism. — The  cirsoid  arterial 
tumor  I  would  define,  after  Robin  and  Gosselin,  as  being  an  elongation 
and  dilatation  of  the  terminal  subcutaneous  arterioles  (normally  of  a 
diameter  of  about  one  fiftieth  of  an  inch).     These  tumors  may  be  general 

*  "  G.1Z.  des  h6pitaux,"  1882,  p.  1083. 


VASCULAR  TUMORS.  187 

or  circiimscribecl.  A  single  arteriole  may  be  affected,  as  shown  in  a 
drawing  in  the  Museum  of  St.  George's  Hospital,  copied  in  Holmes's 
"  Sj'stem  of  Surgery,"'  or  many  arterioles  may  be  involved,  as  in  Mus- 
sey's  remarkable  case. 

The  term  cirsoid  aneurism  was  introduced  by  Breschet,  in  a  paper 
presented  to  the  Academy  of  Medicine,  at  Paris,  in  1832.  By  him  it  was 
applied  to  the  condition  of  varicosity  involving  the  larger  arterial  trunks, 
theu"  branches,  and  the  termuial  arterioles.  Robin,  at  a  later  date,  intro- 
duced the  name  of  cirsoid  arterial  tumors,  and  defined  these  as  varicosi- 
ties of  the  tenninal  (subcutaneous)  arterioles. 

English  writers  have  adopted  the  tenn  employed  by  Breschet.  By 
them  it  is  usually  considered  "a  form  of  disease  which  consists  in  a 
simultaneous  elongation  and  dilatation  of  an  artery.  The  structure  of 
its  wall  exhibits  in  the  beginning  no  alteration,  although  the  coats 
become  thinned  during  the  progress  of  the  enlargement.  Tlie  middle 
coat  of  the  artery  is  especially  affected.  It  becomes  pale  and  thin,  so 
that  the  arteries  look  like  veins.  The  dilatation  is  commonly  equal 
throughout  the  circumference  of  the  artery.  In  more  severe  cases  the 
artery  is  greatly  dilated,  and  presents  unequal,  saccular  pouches,  which 
are  in  fact  so  many  true  aneurisms,  projecting  usually  toward  the  surface 
of  the  skin "  (Holmes). 

Gosselin  *  adopts  the  nomenclature  of  Robin,  and  considers  the  dis- 
ease heretofore  known  as  cirsoid  aneurism  as  only  involving  the  terminal 
arterioles.  The  causes  of  cirsoid  arterial  tumors  are  not  positively 
known.  They  occur  most  frequently  upon  exposed  siirfaces  of  the  body, 
as  on  the  neck,  head,  and  hands.  The  face  and  head  are  most  frequently 
the  seat  of  all  forms  of  vascular  subciitaneous  and  cutaneous  tumors. 
Excluding  those  of  the  orbit,  I  have  collected  more  than  ninety  cases  in 
which  the  carotid  arteries  were  tied  for  these  lesions. 

Polaillon  reports  fourteen  cases  of  cirsoid  aneurism  of  the  hand.  The 
influence  of  exposure  of  an  unprotected  surface  to  atmospheric  changes 
is  worthy  of  consideration.  Either  peripheral  or  central  disturbances  of 
the  functions  of  the  vasomotor  nerves  may  lead  to  loss  of  tone  in  the 
muscular  walls  of  the  arteries.  Frost-bite  and  blows  have  been  mentioned 
as  causes  of  cu-soid  aneiarism.  Berger  reports  a  case  of  cirsoid  tumor  of 
the  hand  caused  by  irritation,  from  constant  pressure  of  an  instrument 
which  the  patient  used  in  his  trade.  The  disease  may  also  be  congenital, 
or  may  result  from  the  increased  growth  of  a  cutaneous  nsevus.  Gosselin 
cites  two  cases  of  this  kind.  He  holds  that  the  presence  of  njevus  indi- 
cates a  congenital  predisposition  to  vascular  dilatation,  and  is  not  sure 
but  that  a  subcutaneous  arterial  dilatation,  at  first  not  recognized,  may 
exist  simultaneously. 

According  to  Holmes,  cirsoid  arterial  tumor  occurs  most  freqiiently 
between  the  ages  of  fifteen  and  thirty.  Wardrop's  patient,  whose  case  is 
given  by  Gosselin  as  one  of  cirsoid  arterial  growth,  was  operated  upon 
the  sixth  week  after  liirtli.     AVardrop  gives  the  case  as  one  of  "  erectile 

*  '■  Archives  g6n6rales  de  m^decine,"  1867. 


188  A  TEXT-BOOK  ON  SURGERY. 

tumor."  Cheliiis  operated  for  "aneurismal  varix  of  the  temporal  region" 
in  a  fliild  of  twelve  montlis. 

Si/tnploms. — The  clhiical  Jilfiforyoi  cirsoid  arterial  tumors  does  not 
commence  with  the  pathological  changes  which  occur  in  the  ternunal 
arterioles.  Dilatation  begins  before  there  is  any  ajipreciable  projection 
of  the  skin,  or  pidsation,  or  twisting  of  the  arterioles.  At  a  later  period 
the  i)hysical  signs  are  present,  and  the  diagnosis  easy.  Dii'ect  pressure 
will  arrest  the  pulsation  and  empty  the  tumor.  The  consistency  of  these 
tnmors  varies  with  the  amount  of  the  connective  tissue  developed  around 
the  arterioles,  as  a  result  of  the  intiammatory  process.  Petit  descril)es 
the  sensation  imparted  to  the  palm  of  the  hand  pressed  upon  an  arterial 
cirsoid  as  similar  to  the  vermicular  motion  of  a  mass  of  earth-worms. 

With  the  stethoscope,  a  bruit  de  souffle  is  distinctly  audible.  Pain  is 
not  constant,  and  is  only  due  to  the  pressure  of  the  growth  ujxm  the 
cutaneous  nerves.  As  the  tumor  progresses  in  size,  more  marked  inHam- 
matory  changes  occur  ;  adliesions  to  the  skin  take  i)lace  ;  and  ulcerations, 
with  alarming  hfemorrhages,  are  not  infrequent.  In  some  instances, 
especially  in  cirsoid  tumoi'  of  the  scalp,  pressure  of  the  growth  upon  the 
calvaria  may  interfere  witli  the  nutrition  of  the  skull. 

Treatment. — It  maybe  said  of  the  treatment  of  cirsoid  arterial  tumors, 
in  common  with  arterial,  capillary,  and  venous  cutaneous  tumors,  that 
no  method  is  as  safe  or  sure  as  direct  local  treatment.  The  study  of  a 
large  number  of  cases  leads  me  to  this  conclusion.  For  a  long  time  deli- 
gation  of  t\\e  main  trunk  or  trunks  was  the  favorite  practice.  Sometimes 
this  was  done  to  arrest  hfcraorvhage  due  to  ulceration  or  accident,  in  some 
few  cases  to  arrest  hgemorrhage  after  or  during  an  attempt  at  removal, 
but  most  frequently  the  intention  was  to  cut  off  the  blood-supply.  Since 
the  vast  maj(nnty  of  vascular  tumors  occupy  the  neck,  face,  and  scalp,  the 
carotids  have  been  often  tied  in  the  treatment  of  these  growths.  In  my 
"Essays  in  Surgical  Anatomy  and  Surgery"*  I  have  collected  98  cases 
of  ligature  of  the  carotid  for  vascular  growth  above  the  clavicle,  and 
chiefly  of  the  head.  This  numl)er  does  not  include  GO  cases  of  pulsating 
vascular  tumor  within  the  orbit.  The  results  are  not  such  as  to  encourage 
the  careful  operator  in  a  repetition  of  the  procedure. 

Even  in  the  nine  cases  in  which  both  common  trunks  were  tied,t  only 
one  was  cured  (not,  however,  until  after  compression  was  made  over  the 
tumor),  and  two  were  improved.  Mussey's  jiatient  was  only  improved 
after  the  second  ligation,  but  was  cured  after  a  bloody  excision.  The 
tumor  was  exceedingly  large,  and  the  dilated  arteries  were  tied  one  by 
one.  More  than  twenty  ligatures  were  applied,  and  the  hsemoiThage  is 
said  to  have  been  dangerously  profuse. 

Other  surgeons  besides  Mussey  X  who  have  practiced  excision  of  cir- 
soid arterial  and  other  "vascular  tumors"  are  Busch,:|:  Heine,:]:  Graefe,* 

*  New  York,  1879. 

t  Tlie  operators  were  Blackman,  Giinderlocli  and  Miiller,  Kiilil,  Mussey,  Pirogoff,  Robert, 
Rodgers  and  Van  Hiiren,  Ullman,  and  Warren. 

X  See  the  author's  "Essays  in  Surgical  Anatomy  and  Surgery,"  New  York,  1879. 

•  Ilolmes's  "  System  of  Surgery,"  second  edition,  vol.  iii,  p.  540. 


VASCULAR  TUMORS.  189 

Gibson,*  Buchanan, f  Sydney  Jones,;]:  Warren,*  Weitzer,*  Giieniot,*  and 
Hart.*  The  latter  froze  the  tumor,  and  cut  well  into  sound  tissue  ;  little 
blood  was  lost.  The  late  Prof.  Spence,  of  Edinburgh,  cured  a  deep-.seated 
erectile  tumor  of  the  hand  by  galvano-puncture.  ||  Nelaton  ojjerated  in 
a  cirsoid  tumor  of  the  forehead  in  a  similar  way,  and  with  like  success. 

Barwell  operates  uj^on  vascular  tumors  V)y  what  is  tei-med  the  scarless 
method.^  Having  carefully  made  out  the  limits  of  the  tumor,  a  needle 
armed  with  a  silver  wire  is  passed  under  the  skin,  and  subcutaneously 
around  the  outskirts  of  the  tumor,  to  a  point  opposite  the  i>lace  of 
entrance.  The  needle  is  again  introduced  at  the  point  from  which  it  has 
just  emerged,  and  is  carried  around  the  remainder  of  the  tumor,  and  out 
at  the  tirst  point  of  entrance.  The  base  of  the  tumor  is  thus  looped  by 
a  wire  which  can  be  tightened  beneath  the  skin  at  will.  Barwell  uses  a 
slot  of  vulcanized  rubber,  which  he  slides  down  upon  the  wire  to  tighten 
it  around  tlie  tumor.  If  the  growth  be  very  large,  he  advises  the  needle 
to  be  brought  out  at  frequent  intervals. 

Dii'ect  local  compression  has  been  tried  by  patient  and  expert  sur- 
geons, Init  has  not  met  with  success. 

Gosselin^  in  his  classical  paper  reports  several  successful  cases  in 
which  he  employed  hypodermic  injections  of  perchloride  of  iron  into  the 
mass.  This  idea  was  original  with  Broca,  who  applied  the  styptic  ender- 
mically  with  success.  Pitha,  of  Prague,  and  Schuh,  following  Broca, 
thus  cured  three  cases  (Gosselin).  BergerJ  rejiorts  a  case  of  cirsoid 
aneurism  of  the  hand  treated  by  this  method.  Yelpeau,  Gherini,  and 
Demarquay  have  jjerformed  the  same  operation.  In  Demarquay's  case, 
the  radial  anil  ulnar  arteries  had  been  tied. 

The  method  of  procedure  is  as  follows  :  The  tumor  must  be  com- 
pressed, so  that,  while  the  circulation  ceases,  the  growth  remains  full  of 
blood.  This  condition  must  be  maintained  for  at  least  ten  minutes  after 
the  injection.  The  syringe  being  tilled,  the  air  is  carefully  excluded,  and 
the  needle  is  introduced  aboiit  a  quarter  of  an  inch  into  the  mass,  when 
the  solution  is  discharged.  Kneading,  to  disseminate  the  fluid,  is  then 
practiced,  and  the  finger  is  placed  ui:)on  the  hole  made  by  the  needle, 
or  the  needle  and  syringe  may  be  left  in,  during  the  ten  minutes. 

Pain  is  immediately  present,  and  persists  for  several  hours.  After  an 
interval  of  ten  or  fifteen  days,  the  operation  may  be  repeated,  if  neces- 
sary. Eight  or  more  operations  have  been  required  to  effect  a  final  cure. 
Ulceration  may  follow,  but  it  is  usually  limited.  At  times,  unhealthy 
granulations  bud  iip  from  these  ulcerating  patches,  requiring  repeated 
burning  with  nitrate  of  silver  or  with  the  actual  cautery. 

*  Holmes's  "System  of  Surgery,"  seeoml  edition,  vol.  iii,  p.  .j-tO. 
t  "  British  Medical  Journal,"'  June,  1875,  p.  835. 

X  "Lancet,"  1882. 

*  See  the  author's  "Essays  in  Surgical  Anatomy  and  Surgery,"  New  York,  1879. 
II  "  Medical  Times  and  Gazette,"  August  21,  1875,  p.  209. 

•»■  "  Lancet,"  May  8,  1875,  p.  642. 

(j  "Archives  gen.  de  medecine,"  torn,  ii,  18G7,  pp.  G36-659. 

%  "  Gazette  des  btipitaus,''  1882,  p.  1082. 


190  A  TEXT-ROOK  ON  SURGERY. 

In  one  of  Gosselin's  cases,  hEomorrliage  was  so  frequent  and  persistent 
that  deligation  of  the  parent  vessel — the  femoral — was  at  one  time  con- 
sidered ;  but  this  was  happily  avoided  by  repeated  use  of  the  actual 
cautery.* 

The  results  of  this  method  of  treating  cirsoid  vascular  tumors  are 
gratifying,  and  the  operation  is  worthy  of  repetition.  In  growths  of 
small  size  I  should  prefer  to  try  the  method  of  Barwell,  and,  if  this  failed, 
then  the  injection  of  perchloride  of  iron  or  other  coagulating  solution. 
The  success  achieved  by  Spence  and  Nelaton  Avitli  galvano-pnncture  was 
such  as  to  justify  further  trial  of  this  method. 

Cases  of  spontaneous  cure  of  vascular  tumors  are  reported.  Dr. 
Krackowizer  presented  to  the  New  Yoi-k  Pathological  Society  a  patient 
in  whom  pulsation  had  entii'ely  ceased  in  a  cirsoid  tumor  which  was 
contracted,  solid,  and  shriveled  at  various  points ;  the  peculiar  rustling 
noise,  also,  of  which  the  patient  had  complained,  was  now  entirely 
absent  when  he  was  quiet.  The  man  was  forty-live  years  of  age ;  the 
tumor  was  congenital,  and  had  grown  to  a  considerable  size,  but  without 
pain  or  liaMuorrhage.  Dr.  Krackowizer  referred  to  two  other  cases  re- 
corded by  Oriila  and  Chevalier. 

*  Gosselin's  cases  wore  three  in  number: 

Case  I. —  Cirsoid  Arterial  Tumor  of  llie  Left  Leg. — Tlie  patient  was  a  woman,  aged  twenty- 
five.  At  birth  slie  had  a  small  red  stain  or  spot  in  the  skin  at  tlie  upper  and  anterior  i)art  of 
the  left  leg,  which  up  to  her  twelfth  year  had  grown  about  as  large  as  an  almond.  At  lifteen 
she  first  noticed  that  pulsation  began  in  it.  After  this  date  it  grew  more  rapidly,  projecting, 
however,  very  sliglitly  from  the  surface,  until,  at  the  ago  of  twenty-two,  it  began  to  ulcerate 
without  any  assignable  cause.  Hajmorrhage  occurred,  which  ceased  by  compression,  but  not 
until  syncope  had  ensued.  Repeated  bleedings  occurred  up  to  her  twenty-fifth  year,  when  the 
injections  were  commenced.  From  July  12th  to  August  23d,  seven  injections  were  made. 
Ulceration  began,  and  frequent  liaBinorrhages  occurred  between  October  12th  and  18th,  which 
were  arrested  by  the  actual  cautery  .and  compression.  Cure  resulted  at  the  end  of  eleven 
months. 

Case  II. —  Cirsoid  Arterial  Tumor  of  the  Foreliead  with  Arterial  Varices;  nmmorrhage 
during  Many  Years;  Four  Injections  of  Perchloride  of  Iron  ;  Cvre. — Patient  was  a  man,  aged 
thirty-nine;  was  born  with  a  red  mark  on  his  forehead,  which  disappeared  at  his  tenth  year. 
About  nineteen  years  later,  when  in  Lis  twenty-ninth  year,  a  tumor  was  noticed  in  the  same 
place,  about  as  large  as  a  cherry-stone,  and  two  years  later  he  felt  it  begin  to  ])ulsate.  After 
that  time  it  continued  to  grow,  and  was  the  source  of  frequent  htemorrhages  without  any 
direct  injury  or  known  cause.  The  patient  had  controlled  the  bleeding  by  compression.  At 
the  time  of  oper.ntion,  the  growth  was  about  two  inches  in  diameter,  and  projected  from  the 
skin  about  one  third  of  an  inch.  February  12th,  while  pressure  was  made  on  both  primitive 
carotids,  injections  were  made  with  two  syringes,  one  needle  being  introduced  on  each  side  of 
the  tumor.  The  compression  of  the  carotids  was  continued  ten  minutes.  The  tumor  still 
pulsated  at  points.  Compress  applied;  pain  was  severe  during  the  day  of  operation  and  the 
nest  day  following.  Operation  repeated  on  the  1st  of  March.  March  1.3th,  tumor  was  solid 
and  without  pulsation  throughout  two  thirds  of  its  extent.  Two  injections  made.  March  20th, 
tumor  began  to  ulcerate  at  two  limited  i)oints,  which  were  soon  filled  with  exuberant  granula- 
tions. These  resisted  alcoholic  dressings  and  the  application  of  nitrate  of  silver.  March  24th, 
pulsation  reappeared  at  one  point,  and  the  injection  was  repeated.  M.ay  2nth,  the  granula- 
tions persisting,  actuiil  cautery  was  ai)plied.  Same  on  June  6th.  July  8th,  patient  discharged, 
cured. 

Case  III  does  not  differ  materially  from  the  two  preceding  cases,  either  as  to  its  clinical 
history  or  as  to  its  treatment. 


VASCULAR  TUMORS.  191 

Angeiomata. — The  three  next  varieties  of  "vascular  tumor,"  which 
may  be  grouped  togetlier  under  the  name  of  Angeiomata,  are :  (1)  The 
Arterial  Cutaneous  Tninor,  or  Aneurism  by  Anastomosis,  composed  of 
dilatations  or  elongations  of  the  arterioles,  either  nomial  or  new-fonned, 
in  the  skin ;  (2)  the  Capillary  Cutaneous  Tumor,  consisting  of  dilata- 
tions and  elongations  of  the  normal  or  new-formed  capillaries  of  the  skin  ; 
and  (3)  the  Venous  Cutaneous  Tumor  [Cacernous  JVoicus),  composed  of 
dilatations  of  the  normal  or  new-formed  venous  radicles  of  the  skin. 

The  angeiomata  are  considered  by  some  writers  as  strictly  new-forma- 
tions of  blood-vessels.  There  is  little  doubt,  however,  that  many  vascular 
tumors  are  chiefly  made  up  of  normal  vessels  which  have  undergone 
dilatation  or  hypertrophy.  Other  names  that  have  been  given  to  angeio- 
mata are  congenital  nsevus,  erectile  tumor,  telangiectasis  or  plexiform 
augeioma,  aneurism  by  anastomosis,  ecchymoma,  cavernous  nsevus,  and 
fungus  hteniatodes.  According  to  Depaul,  one  third  of  the  children  born 
in  one  of  the  eleemosynary  institutions  at  Paris  had  congenital  najvi, 
the  greater  number  of  which  disappeared  spontaneously  during  the  first 
few  months  of  life.  They  occur  chiefly  in  the  skin,  and  are  especially 
apt  to  appear  on  the  forehead,  face,  ears,  and  neck. 

Structure  and  Symptoms. — Angeiomata  commonly  form  flattened, 
slightly  projecting  tumors,  varying  in  size  from  a  mere  speck  to  as  much 
as  an  inch  in  diameter,  and  are  composed  of  new-formed,  dilated,  freely 
anastomosing  capillaries,  arterioles,  and  veins,  in  irregular,  labyrinthine 
masses.  They  vary  in  color,  being  at  times  grayish-blue  or  red.  Often 
the  only  indication  of  their  presence  is  the  appearance  of  a  diffuse  red- 
ness over  a  considerable  surface.  Examined  microscopically,  the  walls 
of  the  vessels  are  crowded  with  cells,  and  the  vessels  are  imbedded  in  a 
netwoi'k  of  fil)rous  and  adipose  tissue.  The  superficial  and  deep  cutane- 
ous vessels — including  the  vessels  of  the  haii-follicles,  sweat-glands,  and 
adipose  tissue — join  in  the  formation  of  these  tumors.  The  disease  may 
extend  into  the  muscles  and  deeper  tissues. 

The  majority  of  angeiomata  are  soft  and  yielding,  and  can  be  emptied 
by  pressure  ;  but  when  of  great  vascularity  and  long  standing,  when  there 
has  l)een  an  extensive  proliferation  of  the  perivascular  connective  tissue, 
pressure  will  not  cause  their  disappearance.  Some  are  very  painful,  and 
others  entirely  free  from  sensibility. 

Venous  cutaneous  tumors  are  composed,  in  great  part,  of  new- formed, 
erectile  tissue,  analogous  to  that  found  in  the  corpora  cavernosa.  Their 
structure  is  white  and  dense,  the  caverns  communicating  freely  with  each 
other.  In  rare  instances  they  are  known  to  contain  chalky  concretions, 
which  are  known  as  pliJeholites.  The  circulation  is  active  in  these 
tumors,  and  their  volume  variable. 

The  walls  of  the  sinuses  contain  a  dense,  fibrous  stroma,  involuntary 
muscular  tissue,  and  striated  muscular  fibers  when  the  tumor  is  encroach- 
ing on  the  muscles.  They  are  lined  by  the  same  endothelium  as  the 
normal  veins.  In  specimens  removed  and  immediately  immersed  in 
alcohol,  it  is  found  that  the  blood  presents  the  same  appearances  as  the 
normal,  with  the  exception  that  the  white  corpuscles  are  less  numerous 


192 


A  TEXT-BOOK   ON   SURGERY. 


(Fig.  2G7).  They  do  not  adhere  to  the  walls  of  the  vessels.  This  is  con- 
sidered as  proof  of  a  rajjid  circulation,  since  in  veins  where  the  ciirulation 
is  weakened  or  retarded  the  leucocytes  tend  to  adhere  to  the  walls.  After 
excision,  the  vessels  contract,  forcing  out  their  contents,  and  the  mass 

shrinks  to  a  comparatively  small  size. 

These  tumors  are  not  all  erectile,  and 
some  which  have  been  erectile  for  a  time 
lose  this  property.  Gross  describes  a  form 
of  ngevoid  tumor  as  ncvroid  elrpJiaiifinsis, 
consisting  of  a  hyi^ertrophied  condition  of 
the  skin  and  subcutaneous  connective  tis- 
sue. The  affection,  which  is  either  con- 
genital or  comes  (m  soon  after  birth,  is 
found  usually  in  the  lower  extremities, 
though  it  may  occur  elsewhere. 


Fio.  2G7. — Caveruous  angeioina  of  tlie  liver. 
Suction  made  after  the  tumor  liad  been 
immediately  submerged  in  alcohol,  a, 
cavernous  sjtaees  filled  with  blood-cor- 
pu>cles  ;  /;,  lihrou-  walls  of  the  sinuses. 
Jlairniliid  l.i"  diameters.  (From  Cor- 
nil  and  Kanvier.) 


The  theories  as  to  the  origin  of  these 
neoplasms  are  various.  Some  hold  that 
simple  dilatation  of  contiguous  veins  oc- 
curs when,  the  sacculated  vessels  coming 
in  contact,  the  walls  are  absorbed,  and 
thus  many  cavities,  which  formerly  were 
separate,  may  form  one  or  more  large, 
multilocular,  cavernous  tumors.  These 
dilatations  occur  not  only  in  the  skin  and 
subcutaneous  tissues,  but  also  in  bone  and 
muscle.  No  tissiie  can  be  considered  exempt.  Eokitansky  holds  that 
they  originate  in  the  areolar  tissue,  from  embryonic,  new-formation  tis- 
sue, and  that  the  vascularization  of  this  new  tissue  is  one  of  the  last 
processes  of  its  develoi)ment.  He  compares  the  alveoli  of  the  cavernous 
angeioma  to  those  of  carcinoma. 

Rindtleisch  believes  that  the  appearance  of  these  tumoi-s  is  preceded 
by  a  proliferation  of  eml)ryonic  material  in  the  intervascular  spaces,  and 
that  this  material,  undergoing  the  usual  process  of  cicatrization  and  con- 
traction, causes  a  shrinkage  in  the  intervascular  arens,  when  the  vessels 
dilate  to  occui)y  the  space  left  vacant  by  the  contracting  tissues  (Billroth). 
Cornil  and  Ranvier  say  that  in  the  active  development  of  angeiomata 
there  is  a  proliferation  of  embryonic  tissue,  rich  in  new-formed  vessels, 
which,  increasing  rapidly  in  size,  come  in  contact  and  communicate  with 
each  other  by  absorption  of  contiguous  surfaces. 

Angeiomata  may  develop  in  fatty  and  other  neoplasms.  Billroth 
mentions  a  case  in  which  a  large  cavernous  angeioma  was  found  in  a 
lipoma  removed  from  the  scapular  region.  They  have  been  known  to 
originate  as  a  result  of  injury.  Gross  cites  a  case,  reported  by  Dr.  .T. 
Mason  Warren,  of  a  man  thirty-six  years  old,  who  had  a  large  aneurism 
by  anastomosis,  situated  on  the  lobe  of  the  ear,  which  resulted  from  a 
frost-bite  which  the  patient  had  suffered  in  his  sixteenth  year.  In  addi- 
tion to  the  tissues  already  mentioned  in  which  angeiomata  are  develoj^ed 
may  be  mentioned  the  spleen,  kidney,  liver,  and  lung.     The  liver  is  fre- 


VASCULAR  TUMORS. 


193 


IP^^^'^^ 


268. — Aneurism  by  anastomosis  in  parietal  bone. 
(Erichsen.) 


quently,  the  lung  very  rarely,  involved.  In  bones,  this  disease  exhibits  the 
same  erectile  characters  as  iu  other  structures  (Fig.  268).  It  occurs  iu  the 
fiat  bones  by  preference,  especially  those  of  the  cranium,  Jaws,  and  scapula, 
being  often  very  painful,  and  grave  as  to  prognosis.  Angeiomata  are  not 
infrequently  situated  on  the 

labia   of    women.      Holmes  ,  ^.-.-j-ij: '-'';' -•-^^■>. 

Coote  has  observed  serous 
cysts  in  connection  with 
these  vascular  growths.  An 
explanation  of  their  forma- 
tion is,  that  communication 
of  a  portion  of  one  dilated 
vessel  with  other  vessels  is 
cut  oflf,  and  that  the  corpus- 
cles and  coloring  matter  of 
the  blood  disappear,  the  se- 
rum remaining  as  a  cystic 
fluid. 

The  question  of  the  rela- 
tion of  these  tumors  to  carcinomata  and  sarcomata  is  worthy  of  consider- 
ation. J.  Miiller  has  reported  a  malignant  (recurrent)  angeioma.  A  case 
of  melanotic  degeneration  of  a  congenital  nsevus  iu  a  woman  aged  forty 
has  been  reported  by  Dr.  Styles.  The  vascular  dilatations  in  osteo-sarco- 
mata,  and  in  other  forms  of  carcinoma  and  sarcoma,  are  analogous  to  those 
found  in  cavernous  angeiomata.  Some  of  the  malignant  tumors  pulsate 
like  the  angeiomata.     An  angeioma  may  be  diffuse  or  encajjsulated. 

The  prognosis  depends  upon  the  size  and  location  of  the  neoplasm. 

The  diagnosifi  is  not  difficult  in  the  superficial  tumors,  but  in  those 
deejjly  situated,  and  in  the  track  of  large  vessels,  the  differentiation  from 
aneurism  is  not  easy. 

The  arterial  and  capillary  cutaneous  tumors  are  almost  always  con- 
genital ;  the  venous  tumors  are  rarely  so.  Angeiomata  may  be  distin- 
guished from  osteo-sarcomata,  which  have  perceptible  pulsation,  by  the 
crackling  impression  conveyed  to  the  sense  of  touch  from  the  malignant 
tumors  of  bone. 

Several  consecutive  telangiectases  may  occur  in  the  same  individual. 
Htitchinson,  of  London,  reports  the  case  of  a  child  which  had  over  one 
hundred  Uccvi,  all  distinct  and  superficial.  Vascular  tumors  on  the  scalp 
have  an  element  of  danger  not  present  in  angeiomata  elsewhere,  in  that 
they  at  times  grow  to  such  an  extent  as  to  cause  necro.sis  of  the  calvaria. 

Treatment. — Angeiomata  have  been  known  to  heal  without  surgical 
interference,  as  a  result  of  an  idiopathic  inflammation.  Transflxion  and 
multiple  deligation  is  one  of  the  most  radical  and  successful  methods  of 
treatment.  Direct  and  prolonged  pressure  has  been  employed,  though 
not  with  encouraging  results.  Perforation  with  hot  needles,  either  with 
or  without  the  galvanic  ciirrent,  injection  of  coagulating  fluids,  particu- 
larly Monsel's  solution,  .50  per  cent  carbolic  acid,  or  of  ergot,  local  apjili- 
cations  of  nitric  acid  or  other  escharotics,  and  extii'i^atiou  by  the  knife. 
13 


194 


A  TEXT-nOOK   ON  SURGERY. 


have  all  been  practiced.     Vaccination  over  the  growth  has  effected  a  cure 
in  a  few  cases. 

In  treating  snpei-ficial  angeiomuta,  not  too  extensive,  and  not  situated 
where  the  cicatrix  would  prove  a  deformity,  50  j^er  cent  carbolic-acid  in- 
jections should  be  emi)loyed.  In  many  cases  coagulation  f)f  the  blood- 
contents  and  ultimate  absorption  will  occur  without  a  scar.  For  extensive 
simple  and  cavernous  angeiomata,  he  recommends  the  knife  or  scissors. 
Haemorrhage  is  to  be  controlled  by  pressure,  rapid  use  of  forceps,  or 
preliminary  ligature. 

Angeioma  of  the  face,  or  of  any  exposed  surface  where  a  scar  is  to  be 
avoided,  is  best  relieved  by  the  clean  cut  of  the  knife,  since  the  cicatrix 
is  less  deforming  than  that  produced  by  other  modes  of  treatment.  I 
have  removed  a  number  of  these  growths  from  the  scalp  and  face.  The 
incision  should  be  made  one  fourth  of  an  iiicli  from  the  edge  of  the 
tumor,  cutting  only  through  healthy  tissue.  AVhen  this  precaution  is 
taken,  hfemorrhage  is  not  dangerous.  Of  course  the  operation  is  not 
justifiable  if  telangiectasis  involves  more  surface  than  can  be  covered  by 
stretching  or  sliding  the  sound  integumpiit.  In  cavernous  tumors  of  large 
size  the  method  of  Erichsen  is  advisable.  A  long,  straight,  or  slight- 
ly curved  needle,  aimed  with 
a  double  thread,  one  half  of 
which  is  stained  black,  is  passed 
through  the  tumor  at  its  base, 
and  deeply  from  side  to  side. 
This  process  is  repeated  at  in- 
tervals of  three  quarters  of  an 
inch,  until  the  entire  mass  is 
transfixed  ^vith  threads  which 
are  parallel  with  each  other  (Fig. 
269).  The  loops  are  then  divided 
— the  black  on  one  side  and  the 
white  on  the  other — and  tied 
tightly  until  the  strangulation 
is  complete.  Kepeated  injec- 
tions of  from  five  to  twenty  minims  of  a  5()-per-cent  solution  of  carbolic 
acid,  at  intervals  of  several  days,  have  succeeded  in  several  cases  of  small 
najvi  about  the  lii)s  and  eyelids. 

Venous  Varix,  Varix,  or  Varicose  Vein. — This  variety  of  "vascular 
tumor"  consists  of  a  dilatation  and  elongation  of  the  deep  or  subcutane- 
ous veins.  This  condition  may  exist  in  any  jiortion  of  the  body,  even  in 
the  bones  (Cornil  and  Ranvier).  It  may  involve  a  small  portion  of  one 
vein,  superficial  or  deep,  or,  as  is  most  usual,  a  chain  of  veins.  It  is  most 
frequently  observed  in  the  superficial  veins,  though  Yerneuil  says  that 
varix  is  really  as  common  in  the  deep-seated  as  in  the  superficial  vessels 
(Bryant).  It  is  especially  prone  to  occur  in  the  saphena  veins.  Hsemor- 
rhoids  and  varicoceles  are  common  forms  of  varix.  Unusual  types  are 
the  dilatation  of  the  jugulars  from  stenosis  of  the  vena  cava  descendens, 
and  that  of  the  superficial  abdominal  veins  from  stenosis  of  the  ascending 


Fig.  269.— Ericlisen's   method  of  introducing  the  double 
li-'ature  for  the  cure  of  vascular  tumors. 


VASCULAR  TUMORS.  I95 

cava.  Such  conditions  are  described  by  some  authors  as  simple  hyper- 
trophies or  dilatations  of  veins.  Any  long-continued  dilatation  consti- 
tutes a  varix.  Hyperplasia  of  the  normal  tissues  of  the  venous  wall  is 
the  natural  sequence  of  prolonged  pressure  and  increased  function.  The 
hypertrophy  of  the  wall  is  not  always  equal  to  the  resistance  of  the  in- 
creased pressure  ;  hence  sacculated  pouches  occur  when  the  vessel- wall 
becomes  much  thinner  than  normal,  not  infrequently  resulting  in  rupture. 
Varix  is  of  frequent  occurrence  in  women  who  have  had  rejieated  preg- 
nancies (Billroth). 

Poorly-fed  and  hard-worked  persons,  especially  those  who  wf)rk  in 
the  upright  posture,  are  more  prone  to  varix  than  others.  Tliere  can  be 
no  doul)t  that  gravitation  is  the  chief  and  immediate  cause  of  this  disease. 
The  veins  most  subject  to  the  greatest,  prolonged  blood-weight,  and  least 
protected  by  pressure,  are  involved  in  the  great  majority  of  cases.  Pa- 
ralysis of  the  muscular  walls,  either  by  atrophy  of  the  muscles  or  inter- 
ference with  the  function  of  the  nerm  vasorimi,  may  cause  varix.  This  is 
proved  by  the  fact  that  a  small  segment  of  a  single  vein  in  the  upper  por- 
tion of  the  body,  where  the  anastomosis  is  free  and  gravitation  can  not  be 
considered  as  a  factor  in  the  dilatation,  may  be  the  seat  of  this  affection. 

In  well-marked  varix  the  veins  are  greatly  increased  in  caliber  and 
in  length,  so  that  they  seem  coiled  and  twisted  upon  themselves  in 
knotted  masses.  They  are  narrowed  in  caliber  at  frequent  intervals, 
these  contractions  ojjening  into  expanded  pouches,  in  general  a]ipearance 
not  unlike  the  sacculated  large  intestine.  The  valves  are  wholly  ineffi- 
cient, often  flattened  against  the  wall,  or  at  times  partially  destroyed. 
At  the  level  of  the  valves  the  walls  are  exceptionally  thickened.  The 
thickening  is  due  to  a  multiplication  of  the  muscular  elements  and  hyper- 
plasia of  the  connective  tissue.  The  connective-tissue  new  formation  is 
aluindantly  distributed  in  the  meshes  of  the  elastic  net-work,  and  the 
bundles  of  fibers  are  usually  arranged  parallel  with  the  long  axis  of  the 
vessel.  This  accounts  for  the  longitudinal  ridges  seen  on  the  inner  sur- 
face of  the  affected  veins  (Cornil  and  Ranvier).  Even  the  nutrient  vessels 
of  the  walls  of  these  varicose  veins — the  vasa  vasorum — have  undergone 
hypertrophy,  and  are  themselves  the  seat  f)f  varix,  forming  at  times 
venous  caverns  in  the  wall  of  the  vessel,  which  communicate  with  the 
vein.  The  internal  tunic  is  not,  properly  speaking,  thickened,  except  at 
the  points  of  attachment  of  the  valves,  or  when  a  thrombus  has  formed. 

Immediately  external  to  the  middle  elastic  tunic,  the  muscular  tissue 
appears  increased  in  quantity,  arranged  in  transverse  and  perpendicular 
laminfe,  separated  by  bundles  of  hypertrophied  connective  tissue,  which 
are  not  infrequently  stained  with  granular  pigment.  Calcareous  deposits 
occur  primarily  within  or  l)etween  these  connective-tissue  bundles  (Cornil 
and  Ranvier).* 

Hyperplasia  of  the  connective  and  other  tissues  in  the  immediate 
vicinity  of  a  varix  of  long  standing  presents  the  usual  appearances  of 

*  In  tlio  arteries,  these  deposits  occur  first  around  and  witliin  the  nucleus  of  the  unstriped 
muscle,  and  jjradually  increase  until  they  fill  the  cell,  which  becomes  converted  into  a  small 
calcareous  flake  (Green).     See  section  on  "  Arteritis." 


196  A  TEXT-BOOK  ON   SURGERY, 

elephantiasis.  Small  si)ots  of  ulceratiou  occur  as  a  result  of  malnutri- 
tion, and,  coalescing,  form  the  large  and  obstinate  ulcers  seen  so  fre- 
quently in  varix  of  the  legs.  Ev<'n  a  new  formation  of  })on(^  niny  result 
from  tlie  irritation  of  a  neighboring  varicosity  (C(jrnil  ami  llanvier). 
The  veins  become  greatly  elongated  and  assume  different  shapes,  irregu- 
lai'ly  sinuous  or  corkscrew-like,  twisted  npon  theii-  axes,  and  frequently, 
on  account  of  perivascular  inflammation,  matted  togetlier  by  new-formed 
connective  tissue  into  venous  tumors.  Occlusion  of  varicose  veins  may 
result  from  thrombosis,  and  a  cure  may  thus  ensue.  Frequently  concre- 
tions are  found  in  varicose  veins,  at  times  adherent  to  the  walls.  These 
concretions  are  called  phlebolithes  or  pldchol'des  (Dunglison).  They  are 
laminated  on  section,  and  are  said  to  contain  by  analysis  20  per  cent  of 
protein  matter,  with  phosphate  and  sulphate  of  lime  and  sulphate  of 
potassium  (Franklin  and  I3ryantj,  and,  according  to  Gross,  a  trace  of 
oxide  of  iron.  They  are  found  most  frequently  in  the  veins  of  the  pelvis, 
about  the  bladder  and  prostate,  especially  when  the  latter  is  enlarged. 
Hodgson  says  that  they  are  formed  in  other  tissues,  and  work  their  way 
into  the  vessels.  This  theory  would  seem  to  receive  a  partial  support 
from  the  statement  just  made,  that  they  are  most  frequently  found  near 
the  prostate,  and  when  this  organ  is  diseased.  It  is  well  known  that 
small  calculi  are  frequent  in  this  body.  Phlebolites  are  also  found  in 
veins  not  subject  to  varix.  Cruveilhier  believed  that  they  were  developed 
from  coagula  (Holmes). 

Treatment. — Varicose  veins  are  to  be  treated  chiefly  by  artificial  sup- 
port to  the  weakened  and  dilated  walls.  Eczema  and  the  various  forms 
of  ulcer  occurring  in  connection  with  varix  are  relieved  by  proper  sup- 
port. The  varix,  however,  is  not  often  cured  by  this  means  alone,  which 
is  merely  palliative.  Martin's  elastic  bandage  is  of  great  use.  Bandages 
of  muslin  or  flannel,  properly  applied,  give  great  relief.  The  elastic  silk 
apparatus,  for  constant,  equable  pressure,  cleanliness,  and  comfort,  can 
not  be  surpassed  in  the  treatment  of  varix.  The  i-elief  of  pressure  by 
position  is  always  advisable.  All  supporting  ajiparatus  should  be  re- 
moved at  bedtime  and  adjusted  before  rising.  The  only  method  of  radical 
cure  is  by  occlusion.  The  use  of  a  subcutaneous  catgut  ligature,  passed 
at  several  points  under  and  not  through  the  veins,  is  the  most  ai)i3roved 
method.  With  careful  antisepsis  and  the  use  of  cocaine  this  procedure 
is  painless  and  not  dangerous.  The  cases  are,  however,  exceedingly  rare 
where  such  procedures  are  necessary. 


Moles. 

Closely  connected  with  the  more  superficial  forms  of  vascular  tumor 
are  the  almormal,  circumscribed  hypertrophies  of  the  skin,  which  are 
known  as  moles.  They  may  be,  and  usually  are,  congenital,  or  they 
may  be  developed  at  any  period  of  extra-uterine  life.  All  portions  of 
the  cutaneous  surface  may  be  the  seat  of  this  form  of  hypertrophy,  but 
the  exjjosed  surfaces,  such  as  the  face,  neck,  and  hands,  are  most  fre- 


MOLES.  197 

qnently  affected.  The  hypertrophy  which  constitutes  the  mole  may 
involve  all  or  any  one  of  the  tissues  which  enter  into  the  anatomy  of  the 
integument.  The  most  frequent  variety  is  that  which  occupies  the  face, 
as  a  simple  elevation  from  which  a  few  stiff  hairs  grow.  It  is  not  stained 
with  pigment,  and  differs  very  slightly,  if  at  all,  in  color  from  the  normal 
skin.  The  lesion  here  is  a  true  hypertrophy  of  all  the  tissues  of  the  skin, 
chiefly  in  the  derma  and  papillary  layer.  The  vascularity  is  slightly 
increased,  and  the  sebaceous  glands  connected  with  the  hair-follicles 
take  part  in  the  hypertrophy.  On  other  portions  of  the  bf)dy  this  form 
of  mole  {ticeims  vulgaris)  will  have  no  hairs  growing  from  its  surface. 

Ncevus  pigmentosus  is  not  usually  a  thickening  of  the  entire  cutis,  as 
is  the  simple  mole  just  described,  but  its  pathological  condition  is  an 
excessive  deposit  of  pigment  in  the  Malpighian  layer  and  in  the  epider- 
mis. It  varies  in  color  from  a  slate-gray  to  a  blue,  mahogany,  reddish- 
brown,  or  wine-coloi-.  At  times  the  pigment  mole  will  extend  over  a 
large  area,  occupying  as  much  as  one  third  or  one  half  of  the  face. 
The  lobule  of  the  ear,  and  the  integument  between  the  eyes  and  over  the 
temple,  is  the  most  common  location  of  this  deformity.  Another  name 
for  these  spots  is  '■^port-wine  marJc.'" 

When  the  hypertrophied  area  of  skin  is  studded  with  hairs,  it  is 
known  as  ncBous  pilostis,  or  hairy  mole.  It  follows  from  the  name  that 
this  form  of  hypertrophy  can  only  occur  on  those  portions  of  the  cutis 
in  which  the  hairs  grow.  The  plantar  surfaces  of  the  feet  and  the  palms 
of  the  hands  are  never  affected.  They  may  or  may  not  be  stained  with 
pigment.     The  majority  of  hairy  moles  are  not  colored. 

Moles,  whether  simple,  hairy,  or  pigmented,  are  benign.  As  a  result 
of  irritation,  they  may  inflame  and  become  ulcerated,  or  may  develop 
into  malignant  growths.  Carcinomata,  especially  of  the  melanotic  variety, 
are  frequently  described  as  having  resulted  from  inflamed  jiigment  moles. 
Alarming  haemorrhage  has  been  known  to  occur  from  a  mole  more  than 
usually  vascular,  in  which  ulceration  had  been  established  by  friction  of 
the  clothing. 

Treatment. — As  long  as  no  deformity  or  inconvenience  results  from 
these  formations,  it  is  better  to  let  them  alone.  When  situated  upon  the 
face,  of  such  size  or  position  that  they  become  offensive  to  the  eye,  they 
may  be  removed  by  simple  excision.  The  incision  should  be  elliptical, 
and  well  away  from  the  growth,  going  entirely  through  the  thickness  of 
tlie  skin.  Tho  wound  should  be  closed  with  line  sutures,  or  drawn 
nicely  together  with  adhesive  strips.  The  simplest  method  of  procedure 
is  to  x^roduce  local  anaesthesia  by  cocaine,  and  operate  quickly.  Port- 
wine  marJis  may  also  be  excised. 

If  a  mole  should  at  any  time  take  on  inflammatory  action,  or  give  any 
indication  of  malignant  proliferation,  immediate  excision  would  be  im- 
perative, and  the  incision  should  be  wide  of  the  supposed  area  of  the 
disease.  The  enqtloyment  of  caustics  or  irritants  of  any  kind  is  to  be 
deprecated,  as  they  would  increase  the  tendency  to  malignant  change  in 
these  growths. 


CHAPTER  X. 


A>^ETJKISM. 


Fig.  2V0. 


Ax  aneurism  is  a  sacculated  tumor,  the  caA'ity  of  which  communicates 
with  an  artery,  and  in  rare  instances  also  with  a  vein. 

They  may  be  classified  as  spherical,  fusiform,  and  dissecting. 
A  S2)lterical  aneurism  is  one  in  which  the  tumor  is  well  defined,  the 
diameter  of  its  cavity  being  larger  than  the  diameter  of  the  opening  of 
communication  with  the  vessel.     It  may  spring  from  any  portion  of  the 

arterial  wall  (Fig.  270,  e),  or,  in 
rare  instances,  the  vessel-walls 
may  yield  in  all  directions  to  foi'm 
the  tumor  (Fig.  270,  c). 

A  fusiform  aneurism  is  one  in 
which  there  is  a  gi-adual  and  gen- 
eral dilatation  of  an  artery  in  its 
entire  circumference  (Fig.  270,  a, 
h).    A  spherical  aneurism  may  oc- 
casionally develoii  from  the  wall 
of  a  fusiform  dilatation. 
A  dissecting  aneurism  is  one  in  which,  owing  to  pathological  changes 
in  the  intima,  with  necrosis,  the  blood  insinuates  itself  between  the  inner 
coat  and  the  adventitia,  dissects  the  intima  from  the  media  and  adven- 
titia,  and  reenters  the  vessel  at  a  distant  opening. 

Aneurisms  are  further  divided  into  the  true  and  false.  To  the  former 
belong  all  tumors  the  walls  of  which  are  composed  of  the  walls  of  the 
vessels  from  which  they  spring  ;  to  the  latter  belong  those  tumors  the 
walls  of  which  are  composed  of  inflammatory  new-formed  tissue. 

Cause. — A  true  aneurism  is  always  preceded  by  arteritis,  which 
results  in  atheromatous  degenei'ution  of  the  normal  elements  which 
compose  the  arterial  wall. 

ThejxitTiologi/  of  arteritis  and  the  relation  of  this  condition  to  various 
dyscrasiffi — as  syphilis,  nephritis,  gout,  rheumatism,  etc. — have  been  fully 
dwelt  on  in  a  preceding  chapter.  These  are  among  the  diseases  which 
are  favorable  to  the  development  of  aneurism.  The  relation  of  violence 
to  these  tumors  must  not  be  lost  sight  of.  No  matter  how  severe  the 
dyscrasia  and  the  general  condition  of  arteritis,  which  is  a  part  of  it,  it 
is  well  known  that  in  the  large  majority  of  cases  aneurisms  develop  at 
those  points  in  the  arterial  system  which  are  subjected  to  the  greatest 


ANEURISM. 


199 


violence  from  hear* -action,  or  muscular  or  mechanical  pressure.  Thus 
the  arch  of  the  aorta,  and  that  portion  of  the  arch  in  the  direct  axis  of 
the  left  ventricle,  is  very  prone  to  aneurism,  as  are  the  great  vessels  near 
their  origin  from  the  aortic  curve.  The  popliteal  arteries,  subjected  as 
they  are  to  violence  in  forced  flexion  of  the  legs,  are  frequently  the  seat 
of  aneurismal  dilatations. 

From  a  study  of  the  various  conditions  which  produce  aneurisms,  it 
is  evident  that  the  normal  wall  of  an  artery  can  not  form  the  sac  of  the 
aneurism.  Some  of  the  normal  anatomical  elements  may  be  present  in 
the  sac,  but  the  integrity  of  the  whole  is  impaired ;  and  it  may  be  that,  in 
the  progress  of  an  aneurism  which  began  in  atheromatous  degeneration  of 
a  part  of  the  elements  of  the  vessel-wall,  all  of  these  elements  will  eventu- 
ally disajjpear,  being  replaced  by  an  inflammatory  new  formation. 

A  sacculated  aneurism  (Fig.  271)  may 
in  rare  instances  communicate  with  a  vein 
{varicose  aneurism).  The  direct  communi- 
cation of  a  vein  and  artery  without  a  sac  is 
known  as  aneurismal  varlx. 

If  an  aneurismal  tumor  be  examined,  it 
will  be  found  to  contain  coagulated  blood 
in  all  stages  of  til)rillation.  The  peripheral 
portion  of  the  clot  is  composed  of  irregu- 
lar lamina,  and,  if  examined  with  the  mi- 
croscope, the  laminated  appearance  is  found 
to  be  due  to  alternate  layers  of  white  cor- 
puscles, and  upon  these  a  deposit  of  fibrin 
(a  condition  which  goes  to  sustain  the 
theory  of  A.  Schmidt,  already  cited,  that  fibrin  ferment,  the  coagu- 
lation factor  of  the  blood,  is  resident  in  the  leucocytes).  As  the  center 
of  the  tumor  is  approached,  the  coagulation  is  evidently  more  recent, 
while  in  the  cavity  of  the  aneurism  a  soft  post-mortem  clot  is  usually 
found. 

Fusiform  aneurism  occurs  most  frequently  in  the  thoracic  aorta,  with 
esjiecial  preference  for  the  arch.  It  may  affect  the  entire  aorta,  and  the 
great  vessels  derived  from  it.  Not  only  is  the  diameter  of  the  arteries 
increased,  but  the  hypertrophy  results  in  a  considerable  increase  in  their 
length.  Not  infrequently  a  grou])  of  fusifoi-m  expansions  may  be  seen 
with  strips  of  sound  and  non-dilated  artery  intervening.  Calcareous 
deposits  occur  in  patches,  and  seem  to  give  strength  to  the  walls,  since 
those  portions  give  way  more  readily  which  are  not  the  seat  of  calcifica- 
tion. 

Coagulation  is  not  apt  to  occur,  as  in  sacculated  aneurisms ;  in  fact,  it 
is  a  rare  condition.  Fusiform  aneurisms  develop  slowly,  and,  as  a  rule, 
are  painful  and  dangerous  cmly  when,  by  reason  of  their  large  growth, 
they  exercise  undue  jiressure  upon  important  organs.  Thus,  in  dilata- 
tion of  the  transverse  arch,  or  of  the  right  subclavian,  spasm  of  the 
glottis  occurs  from  irritation  of  the  recurrent  larjTigeal  nerves,  or  respi- 
ration and  deglutition  may  be  seriously  embarrassed  by  direct  comj)res- 


Varicose  Aneurism.     Aneurismal  Varii:. 
Fig.  271. 


200  A  TEXT-BOOK  ON  SURGERY. 

sion  of  the  trachea  or  o'sopha<?us.  Fusiform  dilatation  of  the  abdominal 
a,orta  may  produce  serious  results  from  disturbance  of  the  vaso-niotor 
system,  by  compression  of  the  sympathetic  ganglia  near  the  diaphragm, 
by  pai'tial  or  ccmiplete  occlusion  of  the  thoracic  duct,  etc. 

Dissecting  aneurisms  are  rare  as  compared  with  the  other  two  varieties. 
The  dissection  or  lifting  of  the  thin  lining  membrane  of  the  artery  fioiii 
the  media  usually  occurs  in  the  hmg  axis  of  the  vessel.  If  tlie  middle 
and  outer  coats  do  not  become  involved  in  the  degeneration  whicli  has 
affected  the  inner  coat,  this  form  of  aneurism  may  continue  indefinitely, 
without  leading  to  a  fatal  termination,  although  the  danger  of  embolism 
can  not  be  overlooked. 

If  the  other  layers  give  way,  a  sacculated  aneurism  is  formed,  with  the 
adventitia  for  the  sac,  or  rupture  may  occur,  leading  to  fatal  extravasa- 
tion. 

A  false,  or  so-called  '■'■diffuse,'"  aneurism  results  from  the  solution 
of  continuity  in  all  the  coats  of  the  vessel-wall,  and  the  sudden  diffu- 
sion of  blood  into  the  peri -arterial  tissues.  The  extravasation  con- 
tinues until  the  resistance  of  tlie  surrounding  tissues  is  equal  to  the 
pressure  of  the  column  of  blood  within  the  vessel.  As  a  result  of  the 
extravasation,  an  intlammatory  process,  of  variable  intensity,  is  estab- 
lished, which  results  in  the  formation  of  a  limiting  membrane,  or  aneu- 
rismal  sac. 

The  prognosis  in  aneurism  varies  under  widely  differing  conditions. 
In  general  it  is  a  grave  affection,  the  gravity  depending,  in  a  great  de- 
gree, upon  the  location  and  character  of  the  tumor  and  the  physical  con- 
dition of  the  individual  affected.  An  aneurism  of  the  cranial  cavity  will 
produce  rapidly  serious  effects  by  compression  of  the  brain.  The  gravity 
of  a  prognosis  diminishes  as  the  location  of  the  tumor  is  removed  from 
the  cavities.  Aneurism  (especially  the  sacculated  variety)  of  the  aorta, 
innominate,  subclavian,  or  iliac  arteries,  is  an  exceedingly  dangerous 
affection,  while  the  same  condition  in  the  distal  arteries  yields  readily 
and  safely  to  surgical  interference  in  the  great  majority  of  cases.  The 
prognosis  may  also,  in  joart,  depend  upon  the  degree  of  discomfort  expe- 
rienced by  the  patient,  from  the  effects  of  pressure  upon  contiguous 
organs.  Neuralgia  of  the  most  painful  and  obstinate  kind,  resulting 
from  pressure  of  the  tumor  ujion  a  neighboring  nerve,  may  hasten  a  fatal 
termination  by  loss  of  sleep  and  rest,  and  the  general  impaii'mcut  of 
nutrition.  Occlusion  of  the  accompanying  vein  may  occur,  i^roducing 
oedema  and  gangrene.  Again,  the  gravity  of  the  prognosis  is  increased 
when,  l)y  reason  of  its  location,  the  sac  of  an  aneurism  is  in  contact  with 
a  bony  surface,  since  rupture  is  not  infrequently  precipitated  by  attrition 
against  the  roughened  bone. 

The  symptoms  of  aneurism  are,  in  great  part,  local.  They  refer  to  the 
direct  development  and  effect  of  the  tumor.  A  sense  of  unusual  throb- 
bing pain,  more  or  less  severe,  and  swelling  in  the  line  of  an  artery  (when 
the  aneurism  is  outside  of  a  cavity)  which  pulsates  with  the  cardiac 
systole,  which,  when  not  resting  upon  a  hard  surface,  is  expansile  in  all 
directions,  and  which  gives  to  the  sense  of  touch  a  tremor  not  easily 


ANEURISM.  201 

described  but  readDy  appreciated,  are  symptoms  which  point  in  general 
to  the  diagnosis  of  aneurism.  The  stethoscope,  applied  to  the  tiimor, 
conveys  to  the  ear  the  peculiar  sound  ("i/'MvY")  caused  by  the  passage 
of  the  blood-current  from  the  narro'.v  vessel  into  the  expanded  aneurismal 
sac  and  out  again.  If  the  tumor  be  situated  upcm  one  of  the  arteries  of 
tile  extremities,  compression  upon  the  cardiac  side  will  cause  a  cessation 
of  the  pulse-tremor  and  bruit,  and  diminution  of  the  swelling,  while 
pressure  upon  the  distal  side  will  temporarily  exaggerate  these  sj^mp- 
toms. 

AVhen  an  aneurism  is  developed  as  a  result  of  a  wound  of  an  artery, 
the  immediate  symptoms  of  hfemorrhage  and  swelling,  with  the  pulsat- 
ing character  of  the  tumor,  will  clearly  indicate  its  presence.  The  diffei'- 
entiation  is  chietiy  between  solid  or  cystic  tumors,  which  develop  along 
the  line  of  the  artery,  and  are  lifted  by  the  arterial  pulsation.  Abscesses, 
or  serous  cysts,  are  the  most  difficult  to  recognize.  In  the  formation  of 
an  abscess  there  is  a  previous  history  of  inflammation.  An  aneurismal 
tumor  expands  equally  in  all  directions,  while  any  other  tumor  travels 
with  the  arterial  pulse  in  one  direction  only — that  of  least  resistance.  In 
cases  of  great  difficulty  of  diagnosis  it  will  be  justifiable  to  aspirate  the 
tumor  with  the  finest  hypodermic  needle. 

Left  to  nature,  the  progress  of  an  aneurism  is,  with  rare  exceptions, 
to  a  fatal  termination.  The  deposit  of  fibrillated  fibrin  within,  and  the 
inflammatory  new-foi'med  tissue  \vithout,  may  retard,  but  rarely  arrests, 
the  progress  of  the  disease.  Added  to  the  danger  of  death  from  rupture 
of  the  sac,  or  compression  of  neighboring  organs,  is  that  of  inflammation 
and  sloughing  of  the  tumor  and  its  contents.  The  hope  of  recovery  is  in 
the  gradual  deposition  of  fibrin  within  the  sac,  causing  its  ultimate  occlu- 
sion, or  that  of  the  vessel  or  vessels  immediately  connected  with  it.  The 
danger  of  gangrene  in  the  parts  beyond  the  tumor  is  lessened  with  the 
gradual  establishment  of  the  collateral  circulation,  while  the  sac  and  its 
contents  are  less  apt  to  inflame  than  when  the  occlusion  is  sudden  and 
the  clot  recent. 

The  treatment  of  aneurism  is  constitutional  and  local.  The  constitu- 
tional treatment  is  directed  toward  the  judicious  support  of  the  physical 
powers  of  the  patient,  the  relief  from  pain,  and  the  production  of  a  con- 
dition of  the  blood  favorable  to  a  deposit  of  fibrillated  fibrin  in  the 
tumor. 

The  local  measures  are  directed  to  the  mechanical  control  and  arrest, 
either  gradual  or  immediate,  of  the  circulation  in  the  aneurism,  with  the 
same  end  in  view,  namely,  the  formation  of  fibrin  within  the  sac. 

Constitutional  measures  alone  offer  little  hope  of  a  cure,  and  are  appli- 
cable only  to  cases  where  the  dangers  of  operative  interference  are  suflH- 
cient  to  contra-indicate  any  surgical  procedure.  In  this  plan  of  treatment 
rest  in  bed  is  the  first  and  essential  requirement.  In  conjunction  with 
this  there  may  be  administered  certain  remedies  which  diminish  the 
rapidity  of  the  circulation,  or  affect  the  blood-vessels  or  blood  in  such  a 
manner  that  the  gradual  deposit  of  fibrin  in  the  sac  is  produced.  V(d- 
salca's  method  of  rest  in  bed,  venesection,  and  gradual  starvation,  in 


202 


A  TEXT-BOOK   ON  SURGERY. 


order  to  slacken  the  blood-current  and  thus  cause  coagulation  in  the 
aneurism,  is  now  almost  entirely  abandoned.  Though  heroic,  this  plan 
of  treatment  is  not  witliout  good  results,  as  will  be  shown  in  the  report 
of  cases  of  special  aneurism  on  a  future  page.* 

Tafnell  modified  Valsalva's  method  by  omitting  blood-letting  and 
substituting  a  restricted  diet,  with  the  minimum  of  fluids.  Eest  in  the 
recumbent  position  must  be  rigidly  enforced.  Amcmg  the  remedies 
which  have  been  recommended  for  internal  administration,  iodide  of 
potassium,  fluid  extract  of  ergot,  alone  or  with  infusion  of  digitalis,  and 
tincture  t)f  the  chloride  of  iron,  are  worthy  of  consideration. 

Among  the  many  surgical  procedures  instituted  for  the  relief  of 
aneurism,  those  two  which  deserve  the  first  consideration  are  compression 
and  the  ligature.  In  the  results  achieved  in  their  various  methods  of 
application  all  other  treatment  may  be  practically  excluded. 

Compression  may  be  employed  on  the  cardiac  side  of  an  aneurism, 
close  to  the  tumor,  without  an  intervening  collateral  branch,  or  at  a  dis- 


Antyllus's  method.        WarJrop's  method. 


Anel'8  method. 
Fig.  272. 


Hunter's  method.     Brasdor's  metliod. 


tance  from  the  sac,  with  one  or  more  intervening  branches.  It  may  be 
employed  on  the  distal  side,  with  or  without  intervening  anastomosis,  or 
directly  to  the  surface  and  back  of  the  tumor,  or,  again,  on  both  i)eriph- 
eral  and  central  sides,  with  or  without  direct  compression  of  the  aneurism. 
The  ligature  may  be  applied  on  the  cardiac  side  of  the  tumor,  there 


■  See  "Subclaviau  Aneurism,"'  fuurteen  cases  by  Valsalva's  method. 


ANEURISM. 


203 


being  one  or  more  branches  given  off  between  the  ligature  and  the  sac 
(Hunter's  method),  or  without  an  intervening  branch  (Anel),  or  on  the 
distal  side  without  (Brasdor),  or  with  (Wardrop)  an  intervening  branch, 
or  close  to  the  tumor  on  both  the  distal  and  cardiac  side,  with  or  without 
extirpation  of  the  tumor  (Antyllus)  (Fig.  272). 

When  interrupted  pressure  upon  the  main  trunk,  on  the  cardiac  side 
of  an  aneurism,  is  laossible,  it  is  the  lirst  method  of  treatment  to  be 
adopted.  It  can  only  be  contra-indicated  when  the  tumor  is  so  near  to 
the  great  cavities  from  whicli  the  arteries  emerge  that  there  is  not  suffi- 
cient room  for  its  accomplishment,  or  when,  on  account  of  the  anatomical 
arrangement  of  contiguous  nerves  and  veins,  compression  is  jjainful  or 
inexjiedient,  or  when,  as  will  occur  only  in  exceptional  instances,  rupture 
is  imminent ;  then  the  ligature  is  demanded. 

Comi)i"ession  may  be  manual  or  instrumental,  and  continuous  or  in- 
terrvpted. 

Given  a  popliteal  aneurism,  as  an  illustration,  comi^ression  on  the 
cardiac  side,  with  an  intervening  branch,  may  be  employed  as  fol- 
lows : 

Digital  or  Manual. — The  jiatient,  being  placed  in  a  position  comfort- 
able to  himself  and  convenient  to  the  operator,  is,  if  the  necessity  de- 
mands, put  under  the  iniiuence  of  an  opiate  or  ansesthetic.  Comi^ression 
is  then  made  with  the  pulp  of  the  thumb  laid  upon  the  femoral  artery, 
just  where  it  crosses  the  rim  of  the  pelvis,  until  pulsation  in  tlie  tumor  is 
diminished  or  arrested.  Additional  force  is  gained  by  pressing  the 
thumb  or  fingers  of  the  opposite  hand  on  the  dorsum  of  the  thumb  first 


employed.  "When  from  fatigue  further  compression  is  impossible,  the 
operator  is  relieved  by  the  next  of  the  detail,  and  so  on.  After  a  lapse 
of  from  two  or  three  hours  to  at  times  as  much  as  three  days,  the  tumor 
ceases  to  pvdsate,  becomes  firm  and  inelastic,  and  remains  permanently 
occluded. 


204 


A  TEXT-BOOK   ON  SURGERY. 


Mechanical. — A  iiK-thod  less  tircsoiiu;  to  the  operiitDi',  no  more  uiinoy- 
ing  to  the  patient,  and  almost,  if  not  equally,  as  effective,  is  as  follows: 
One  or  two  sticks  of  liard  wood  about  an  inch  in  diameter,  and  from  four 
to  six  feet  in  length  (small-sized  hoojj-poles  or  a  crutch  will  sullice),  are 
covered  at  one  end  with  an  India-rubber  tiji,  or  comju'ess  of  some  soft 
substance.  The  other  end  is  tied  to  the  ceiling  with  a  string  or  to  a  bar 
over  the  bed,  and  allowed  to  descend  until  the  tipped  extremity  rests 
with  the  requii-ed  weight  upon  the  vessel  to  be  compressed  (Fig.  273). 
Ifc  may  be  convenient  to  employ  two  poles,  so  that  one  may  press  a  few 
inches  lower  down  than  the  other.  If  one  is  employed,  the  assistant  or 
jiatient  can  be  directed  to  change  the  point  of  pressure  at  intervals,  in 

order  to  prevent  pain  or  ex- 
coriation .  For  this  same  pur- 
pose the  late  Prof.  Alpheus 
B.  Crosby  successfully  em- 
ployed an  elastic  tube  par- 
tially tilled  with  shot  to  give 
it  the  requisite  weight,  'i'he 
tube  was  suspended  above 
the  bed  and  the  pressure 
regulated  by  the  quantity  of 
shot. 

Various  tourniquets,  with 
one,  two,  or  three  compres- 
sion-pads,   have    been    used 
with  the  same  object  in  view, 
and  with  varying  success.     Among  the  better  of  these  instruments  is  Dr. 
Briddon's  compressor  (Fig.  274). 

Compression  with  the  mechanism  just  described  ma}^  also  be  em- 
ployed (m  the  distal  side  of  the  aneurism,  although  with  less  hope  of 
success  than  in  pressure  on  the  cardiac  side,  which  is  among  the  most 
successful  of  the  conservative  methods  at  the  surgeon's  command. 

Direct  i^ressure  upon  the  aneurismal  tumor  has  been  employed  in  a 
few  instances  with  a  fair  degree  of  success.  Six  cases  of  subclavian 
aneurism  treated  in  this  manner  will  he  given  hereafter,  with  description 
of  the  Tuechanism. 

Pressure  on  both  the  distal  and  cardiac  sides,  with  or  without  direct 
pressure  on  the  tumor,  has  been  practiced  by  the  employment  of  Es- 
march's  bandage.  The  patient  being  anaesthetized,  the  bandage  is  ap- 
plied, beginning  at  the  extremity,  and  emptying  the  vessels  by  using 
sufficient  force  in  its  application,  until  the  lower  border  of  the  tumor  is 
reached.  In  passing  over  the  aneurism,  about  one  half  the  pressure  is 
employed,  it  being  intended  to  leave  a  certain  quantity  of  blood  within 
the  sac.  As  soon  as  the  upper  l)oundary  is  reached,  the  same  degree  of 
pressure  is  applied  as  below,  and  the  bandage  is  left  on,  or  the  tubing 
may  be  tightened  around  the  limb  above,  and  the  bandage  removed. 
Cures  have  been  effected  within  an  hour  by  this  practiee,  while  the  com- 
I^rsssion  has  been  exercised  for  several  hours  witii  negative,  and  in  some 


Fig.  274. 


ANEURISM.  205 

instances  with  fatal,  results.  The  method  is  inferior  to  digital  or  me- 
chanical compression  on  the  cardiac  side  of  the  tumor,  and  is  decidedly 
more  dangerous. 

Esmarch  reports  two  cases  of  femoral  aneurism  in  which  the  bandage 
failed,  while  the  pole  or  stick  compressors  were  subsequently  successful 
in  each  instance. 

In  the  ajiplication  of  the  ligature  the  method  of  Hunter  is  generally 
preferable.  The  advantages  of  this  method  over  that  of  Anel  may  be 
enumerated  as  follows  :  The  ligature  is  applied  at  a  distance  from  the 
aneurism  where  the  artery  is  more  apt  to  be  in  a  healthy  condition,  thus 
diminishing  the  danger  of  secondary  hjemorrhage.  The  existence  of  one 
or  more  collateral  branches  between  the  ligature  and  the  tumor  renders 
the  process  of  coagulation  in  the  sac  less  rapid,  and  consequently  less 
liable  to  inflammation  and  sloughing.  The  only  objection  to  this  method 
of  operating  is  the  possibility  of  failure  du3  to  too  free  anastomosis, 
whereby  the  necessary  diminution  of  the  circulation  is  prevented. 

The  method  of  Anel  is  at  this  date  rarely  perfonned,  except  in  those 
Instances  where,  on  account  of  the  location  of  the  tumor,  other  methods 
are  impossible. 

Deligation  upon  both  sides  of,  and  close  to,  the  tumor  (method  of 
Antyllus)  is  not  a  recognized  practice  except  in  peculiar  cases,  where 
other  and  less  radical  methods  have  failed.  It  is  especially  adapted  to 
cases  of  aneurismal  tumors  which  have  numerous  anastomoses  connecting 
directly  witli  the  cavity  of  the  sac,  as  is  not  infrequent  in  popliteal  aneu- 
rism. That  part  of  the  operation  of  Antyllus  Avhich  consisted  in  incision 
of  the  tumor  and  packing  the  sac  is  seldom  considered  necessary,  the 
double  ligature  being  sufficient. 

The  operations  of  deligation  upon  the  distal  side  of  an  aneurism,  so 
close  to  the  tumor  that  no  collateral  branch  intervenes  (Brasdor),  or  at  a 
point  more  remote  with  one  or  more  collateral  branches  intervening 
(Wardrop),  are  procedures  which  have  been  frequently  employed,  espe- 
cially within  the  last  few  years.  Preference  is  given  to  Wardrop's  opera- 
tion over  that  of  Brasdor,  for  the  same  reasons  advanced  in  favor  of 
Hunter's  operation,  as  compared  to  that  of  Anel  on  the  cardiac  side,  to 
which  it  may  be  likened.  There  is  no  evidence  that  Brasdor  ever  did 
more  than  suggest  the  distal  operation.  Deschamp  was  the  first  to  per- 
fonn  it  (Oct.  6,  1708\  but  without  success.  Wardrop  modified  the  opera- 
tion and  established  it  by  successful  practice  in  1825.*  The  general 
results  of  this  procedure  have  been  such  as  to  encourage  its  repetition, 
although  the  manner  in  which  i\  jxyrfial  arrest  of  the  circulation  through 
an  aneurism  by  deligation  on  the  distal  side  of  the  tumor  induces  coagu- 
lation in  the  sac  is  difficult  of  explanation. 

As  hns  been  said  in  the  chapter  on  "  Surgical  Dressings,"  none  but 
animal  ligatures  should  be  applied  to  arteries.  Antiseptic  catgut  of 
the  largest  size  for  the  larger  vessels  will  be  found  most  convenient. 

*  See  article  by  tlie  author,  "  Amcrioan  .Joiirn.il  of  the  Medical  Sciences,"  January,  1881, 
p.  155 ;  and  "  Prize  Essay  of  the  American  Medical  Afsoeiation,"  1878,  p.  9-t. 


206  A  TEXT-BOOK  ON  SURGERY. 

Barwell's*  ox-aorta  ligatures  are  safe  and  efficient,  as  are  those  made 
from  nerves  and  first  used  upon  the  living  subject  by  myself;  but  the 
catgut  is  more  readily  obtained  and  of  more  general  a])])licati<)n  thau 
any  other  material.  I  have  used  the  broad  ox-aorta  (Mr.  Barweirs)  liga- 
ture successfully  in  tying  the  common  carotid  and  the  subclavian  arteries, 
and  have  twice  deligated  the  common  carotid  with  success,  em])loying 
the  sciatic  nerve  of  a  calf  ;  f  but  the  readiness  with  which  catgut  is  ob- 
tained, and  the  ease  and  comparative  safety  of  its  application,  especially 
with  the  aid  of  antiseptic  precautions,  have  led  me  to  give  to  it  the 
preference. 

Other  methods  of  treatment  of  aneurisms  which  have  almost,  if  not 
entirely,  fallen  into  disuse  are  r/aloano-puncfi/re,  massage  or  Jcneadiiiff, 
flexion^  the  introduction  of  horse-hair  or  icire  into  the  sac,  acupuncture, 
and  the  injection  of  a  coagulating  substance  into  the  sac  or  the  tissues 
around  it. 

In  my  opinion,  the  circumstances  which  would  justify  any  of  these 
methods  are  so  rare — if,  indeed,  they  ever  exist — that  they  scarcely  de- 
serve recognition  in  practical  surgery. 

In  galvano-puncture  one  or  more  needles,  connected  with  both  poles 
of  a  galvanic  battery,  are  introduced  into  the  cavity  of  the  sac  on  oppo- 
site side  or  points  of  the  tumor.  They  do  not  touch  within  the  aneurism, 
the  circuit  being  completed  l)y  the  blood.  A  twenty-four-cell  battery 
may  be  used,  beginning  with  a  few  cells  and  gradually  increasing  the 
strength  of  the  current  until  the  usual  pain  is  felt  at  the  negative  pole, 
or  until  signs  of  coagulation  are  evident.  The  objections  to  this  method 
are  that  the  clot  is  of  rapid  formation,  may  not  be  permanent,  and  may 
inflame  and  suppurate,  causing  death  from  haemorrhage  or  septicaemia. 

Massage  or  kneading  has  been  successfully  performed  in  a  few  in- 
stances. The  aneurism  is  manijiulated  with  the  intention  of  detaching 
from  the  sac  enough  of  the  fibriUated  clot  to  plug  up  the  efferent  vessel 
and  thereby  practically  tie  the  arteiy  on  the  distal  side  (Brasdor).  It  is 
a  safer  and  surer  method  than  galvano-puncture,  though  of  doubtful 
propriety  except  in  small  aneuiisms  situated  in  the  aims  or  legs.  The 
danger  of  embolism  in  the  cerebral  circulation  is  too  great  to  justify  this 
or  any  similar  jjrocedure  uj)on  an  aneurism  connected  with  a  vessel  lead- 
ing toward  the  brain. 

Flexion  or  posture  is  practically  a  method  of  direct  compression, 
using  the  normal  tissues  for  a  pad.  It  is  employed  in  popliteal  aneu- 
rism, where  the  knee  is  flexed  and  fastened  so  as  to  compress  and  par- 
tially occbide  the  tumor  between  the  tibia  and  fll)ula,  and  the  femur. 
It  is  a  justifiable  method  in  rare  instances.  .The  same  practice  -may  be 
instituted  at  the  elbow,  but  is  imj^racticable  at  the  axilla  on  account  of 
the  arrangement  of  the  nerves. 

The  introducticm  of  icatcJi-spring  wire,  horsehair,  catgut-coil,  or  any 
other  foi'feign  solid  substance  into  the  cavity  of  an  aneurism  will  rarely 

*  See  article  by  the  author  in  "xVrchives  of  Medicine,"  June,  1882.  G.  P.  Putnam's  Sons, 
New  York.  t  Ibid. 


SPECIAL  ANEURISMS.  207 

be  justifiable  except  as  a  last  resort  in  cases  where  the  ligature  or  com- 
pression is  impossible.  For  its  execution  a  pointed  canula  is  iisuaUy 
employed,  ^Ybich,  having  been  introduced  into  the  sac,  the  wire  or  gut  is 
pushed  through.  The  quantity  used  varies  from  two  or  three  feet  up  to 
several  yaixls.  More  of  the  catgut  may  be  introduced  than  of  the  metal, 
and  the  animal  ligature  should  always  be  j^referred  if  this  procedure  is 
adopted. 

Acupuncture  is  the  operation  of  introducing  needles  into  the  cavity 
of  the  sac,  and  allowing  them  to  remain  for  several  hours  iintil  coagula- 
rion  ensues.  It  is  not  a  scientific  procedure,  and  the  same  must  be  said 
of  the  injection  of  ergot,  the  iron  solutions,  or  any  coagulating  substance 
into  the  cavity  of  the  tissues  around  an  aneurism. 


Special  Aneurisms. 

Aneurism  of  flie  TTioracie  Aorta. — The  ascending  and  transverse 
portions  of  the  arch  are  most  frequently  affected.  If  the  dilatation  is 
fusiform,  both  of  these  segments  are  apt  to  be  involved  ;  if  it  is  a  sac- 
culated aneurism,  it  is  usually  confined  to  one  or  the  other  segment. 
Sacculated  aneurism  of  the  ascending  arch  higli  up,  or  of  the  transverse 
arch,  usually  involves  the  orifice  of  one  or  more  of  the  great  vessels 
which  originate  here,  although,  as  in  the  specimen  figured  below  (see 
Fig.  275),  not  infrequently  the  mouth  of  the  sac  opens  close  to  these  ves- 
sels, but  does  not  involve  them. 

The  diagnosis  of  aneurism  of  the  arch  is  generally  obscure  until  the 
dilatation  has  advanced  to  such  an  extent  that  pressure-symptoms  are 
evident.  Pain  of  varying  intensity  may  be  present  in  the  earlier  stages 
of  development  of  both  fusiform  and  sacculated  aneurism.  A  symptom 
of  great  diagnostic  value  is  disturbance  of  the  laryngeal  muscles,  due  to 
pressure  upon  the  recurrent  laryngeal  nerve  of  the  left  side.  Tliis  occurs 
in  dilatation  of  the  transverse  or  descending  segment  of  the  arch.  The 
aneurismal  bruit  may  be  recognized  as  soon  as  the  sacculation  is  well 
advanced.  Interference  with  respiration,  or  deglutition,  or  the  return 
circulation  in  the  veins,  is  among  other  and  important  pressure-symp- 
toms. 

The  api")earance  of  a  tumor  with  an  expansile  pulsation  synchronous 
with  the  cardiac  systole,  in  the  upper  thoracic  region,  determines  the 
diagnosis  of  aneurism.  The  differentiation  of  dilatation  of  the  arch,  trora 
a  similar  condition  of  the  innominate,  left  carotid,  or  left  subclavian  in 
the  thorax,  is  difficult,  and  at  times  impossible.  A  number  of  errors  in 
tiiagnosis  by  competent  and  honest  obseiTers  are  on  record. 

Tlie  following  points  will  aid  in  arriving  at  a  diagnosis :  The  tumor  in 
aneurism  of  the  ascending  arch  is  usually  first  appreciated  to  the  right  of 
the  sternum,  between  the  clavicle  and  the  third  rib.  The  pressure-symp- 
toms do  not  affect  the  voice  until  the  tumor  is  recognizable  in  the  right 
side  of  the  root  of  the  neck,  where  it  involves  the  right  recurrent  laryn- 
gep,l  nerve.     Respiration  may  be  interfered  with,  or  cough  produced  by 


208  A  TEXT-BOOK  ON  SURGERY. 

compression  of  the  right  bronclius.  Tliis  condition  will  be  recognized  by 
the  hissing  niles  distributed  over  the  areii  of  the  right  lung.  Aneurism 
of  the  transverse  iirch  is  usually  first  recognized  to  the  left  of  the  sternum 
on  about  the  same  i)lane  as  for  the  ascending  segment.  Laryngoscoi)ical 
examination  will  demonstrate  that  whatever  of  muscular  paresis  exists 
is  confined  to  the  left  vocal  bands.  If  the  tumor  rises  into  the  neck,  its 
appearance  will  have  been  preceded  by  pressure-sym])tonis  of  longer 
duration  and  greater  severity  than  in  either  innominate,  carotid,  or  sub- 
clavinn  aneurism. 

Innominate  aneurism  usually  appears  at  the  njijier  margin  of  the 
sternum  in  the  space  between  the  two  tendons  of  origin  of  the  right 
sterno  mastoid  muscle,  or  in  the  interclavicular  notch.  The  disturbance 
of  the  circulation  through  this  vessel  so  affected  maybe  recognized  by 
the  difference  in  the  force  and  character  of  the  pnlse-wave  in  the  radial 
arteries  of  the  two  arms.  lu  aortic  aneurism,  when  the  innominate  is 
not  compressed  liy  the  tumor,  the  pulse-wave  will  be  the  same  in  both 
arms.  It  must,  however,  be  borne  in  mind  that  in  sacculated  aneurisms, 
springing,  as  they  not  infrequently  do,  from  the  arch  in  immediate  prox- 
imity to  the  orifice  of  the  innominate,  and  rising  to  the  root  of  the  neck, 
in  front  of  or  behind  this  artery,  a  positive  diagnosis  is  scarcely  possible. 
The  pressure  on  the  innominate  may  retard  or  weaken  the  right  radial 
pulse,  when  this  vessel  is  not  involved,  while  the  aneurismal  bruit  is 
present  in  the  exact  location  of  this  vessel. 

Aneurism  of  the  left  carotid  artery  will  first  appear  at  the  left  sterno- 
claviciilar  articulation  in  the  line  of  this  vessel.  The  murmur  will  be 
transmitted  toward  the  distribution  of  this  vessel,  and  will  not  be  heard 
in  its  fellow  opposite. 

When  the  left  subclavian  is  involved,  the  swelling  will  usually  appear 
to  the  left  of  the  sterno-mastoid  muscle,  and  the  pulse  in  the  left  radial 
will  differ  from  that  of  the  right.  When  the  descending  aort*  is  the  seat 
of  aneurism,  the  diagnosis  is  still  more  obscure.  The  peculiar  murmur 
is  most  easily  recognized  by  placing  the  stethoscope  to  the  left  of  the 
vertebral  column  in  the  interscapular  space.  The  chief  pressure-symp- 
toms are  those  which  affect  deglutition  and  lift  the  heart  forvvai'd. 

The  cUnical  history  of  aneurism  of  the  thoracic  aorta  usually  ends  in 
the  death  of  the  individual.  In  addition  to  the  symptoms  given  in  the 
method  of  diagnosis,  the  gradual  expansion  of  the  tumor  leads  to  more 
painful  and  graver  conditions.  Anxiety,  loss  of  sleep,  pain,  and  cough 
usually  prostrate  the  patient ;  erosions  of  the  ribs,  sternum,  clavicles,  and 
vertebrje  occur,  and  sloughing,  septic  absorption,  or  hsemori'hage  may 
produce  a  fatal  termination. 

The  medical  treatment  is  rest  in  bed,  and  the  safe  and  Judicious  com- 
bination of  Valsalva's  and  Tufnell's  methods  as  given.  The  surgical 
treatment  is  of  the  most  heroic  order,  and  should  not  be  instituted  until 
a  reasonable  trial  of  the  other  methods  has  proved  them  as  inefficient,  as 
death  is  inevitable.  This  treatment  is  the  deligation  of  one  or  more  of 
the  great  vessels  which  are  derived  directly  or  indirectly  from  the  arch — 
i.  e.,  the  distal  operation. 


SPECIAL  ANEURISMS. 


209 


That  this  operation  is  justifiable,  under  certain  conditions,  has  beer 
demonstrated.  Among  a  number  of  cases  in  the  statistics  of  this  pro- 
cedure, the  following  is  from  i)ersonal  experience  : 

On  the  21st  of  September,  1880,  I  tied  the  right  carotid  and  subclavian 
arteries  simultaneously  for  the  relief  of  an  aneurism  of  the  ascending 
portion  of  the  aorta.*  The  history  of  the  aneurism  dated  back  sixteen 
months.  Having  developed  rapidly,  it  projected  through  the  right  second 
intercostal  space,  causing  siich  pain  that  the  operation  was  undertaken. 


Fig.  275. — The  author's  case  of  aneurism  of  the  ascending  aorta. 

This  was  the  second  operation  which  had  knowingly  been  undertaken 
for  the  relief  of  aneurism  of  the  ascending  aorta.  The  ligatures  used 
were  of  ox-aorta,  and  were  as  large  as  the  median  nerve  in  an  adult. 
Despite  the  ju'ostrated  condition  of  the  patient,  she  recovered,  the  tumor 
diminished  perceptibly  in  size,  became  more  solid,  and  her  general  con- 
dition was  much  improved.     One  month  after  the  operation  she  was  dis- 

*  For  a  full  roport  of  this,  and  all  the  other  cases  up  to  that  date,  see  paper  by  the  author  in 
•'  American  Journal  of  the  Medical  Sciences,"  January,  1881. 
U 


210 


A  TEXT-BOOK  OX  SURGERY. 


charged  from  the  h<)si)ital,  traveled  to  a  neighboring  State,  where  she 
died,  one  year  later,  from  acute  diarrhoea.  I  secured  an  autopsy,  which 
revealed  an  aneurism  (Figs.  27."),  27f))  as  large  as  an  orange  springing  from 
the  ascending  aorta,  at  its  junction  with  tlie  transverse  segment.  The 
orifice  of  the  tumor  was  an  oval,  about  half  an  inch  by  one  inch  in 
extent.  The  tumor  was  solidified  with  permanent  clot  on  its  lateral  and 
posterior  aspects.  On  the  upi)er  anterior  surface,  which  had  worn  away 
the  sternum  and  second  rib,  the  sac  was  thin,  with  a  recent  clot  which 


FiQ.  276. — Section  through  the  long  diameter  of  the  tumor. 

filled  a  cavity  not  quite  an  inch  in  diameter.  The  tumor  was  practically 
solidified,  and,  had  this  patient  not  returned  to  her  dissipated  practices 
(alcoholism),  I  do  not  doubt  that  her  recovery  would  have  been  com- 
plete. Prof.  H.  B.  Sands  i)erformed  the  same  operation  in  1866,  for  a 
supposed  innominate  aneurism.*  The  tumor  diminished  after  the  opera- 
tion, and  visible  pulsation  ceased.  The  patient  died,  thirteen  months 
later,  from  the  pressure  of  the  tumor  which  sprang  from  the  junction  of 

*  See  "American  .Jourruil  of  the  Medical  Sciences,"  January,  1881. 


SPECIAL  ANEURISMS.  211 

the  ascending  and  transverse  segments,  just  in  front  of  the  innominate. 
C  F.  Maunder's  patient  died,  on  the  tifth  day,  from  occlusion  of  the  aorta 
l)y  a  clot  which  projected  from  the  aneurismal  sac.  The  tumor  sprang 
from  transverse  segment,  a  little  to  the  left  of  the  innominate.*  Heath's 
patient  lived  four  years  after  the  double  distal  ligature.  The  aneurism 
diminished  in  size,  and  the  general  condition  was  much  improved.  The 
sac  ultimately  Inirst,  with  a  fatal  result.  The  tumor  originated  from  the 
ascending  aorta.f  Mr.  Richard  Barwell  and  Mr.  Lediard  have  also  per- 
formed this  operation  for  aneurism  of  the  arch.  Mr.  Barwell's  patient 
died  lifteen  months  after  the  operation,  dying  from  dissijiation  and 
" general  wearing  out.''  The  aneurism  was  completely  filled  with  lami- 
nated clot.     Mr.  Lediard's  patient  survived  ten  months.:]: 

Hobart  tied  the  right  subclavian  in  its  first  division,  and  the  right 
common  carotid,  for  a  supposed  innominate  aneurism.  Fatal  hfemor- 
rhage  occurred  from  the  seat  of  ligature  on  the  carotid  on  the  sixteenth 
day.  The  autopsy  showed  a  pyriform  aneurism  originating  from  the 
aorta,  just  to  the  left  of  the  innominate.  The  sac  was  filled  with  a  firm 
coagulum.* 

Thus,  of  seven  cases  of  simultaneous  deligation  of  the  right  carotid 
and  right  subclavian  arteries,  two  died  on  the  fifth  and  sixteenth  days, 
resi^ectively,  from  the  effect  of  the  operation.  The  remaining  five  recov- 
ered, with  evident  improvement.  A  point  of  great  interest  is  to  notice 
the  effects  of  the  operation  tipon  the  tumor. 

In  my  case  there  was  no  immediate  change  in  the  aneurism.  Within 
twenty-two  hours  the  diminution  was  evident,  and  by  thp  fourth  day  it 
had  shrunk  from  an  elevation  of  one  inch  and  a  half  above,  down  almost 
to  the  level  of  the  skin  upon  the  thorax.  In  Sands's  case  "  the  tumor 
diminished  after  the  operation,  and  visible  pulsation  ceased."  There  Avas 
no  diminution  in  Maunder's  case,  but  after  death  the  sac  was  almost  com- 
pletely filled  with  recent  clot,  which  had  even  occluded  the  aorta.  In 
Heath's  case  "  the  tumor  gradually  diminished  in  size."  The  symptoms 
so  far  disappeared  in  Barwell's  patient  that  that  surgeon  informed  me, 
"  The  aneurism  is,  judging  from  symptoms,  cured."  In  Lediard's  case  the 
"laryngeal  symptoms  disappeared  ;  the  tumor  had  a  more  consolidated 
feeling."     The  sac  in  Hobart's  case  "  was  filled  with  firm  coagulum." 

The  evidence  in  these  cases — which  are  all  I  have  been  able  to  collect 
— in  which  the  right  subclavian  and  right  carotid  arteries  were  simidtane- 
ously  tied  for  aneurism  of  the  arch  of  the  aorta,  involving  the  last  portion 
of  the  ascending  segment,  or  the  first  portion  of  the  transverse  segment, 
or  both,  points  to  the  conclusion  that,  in  sacenlated  aneurism  affecting 
the  arterial  limit  just  gipen,  the  double  distal  ligature  tends  to  produce 
consolidation  of  the  tumor,  and  to  relieve  the  symptoms  of  distress 
caused  by  its  presence. 

*  See  "  Anieviciiii  .Joiiriuil  of  the  MoJioal  Sciences,"  January,  1881. 
t  Ibid. 

X  Autlior's  article  on  Distal  Lifiatiire  for  Aneurisms  near  tbe  Heart,  "iVnierican  Journal  of 
the  Medical  Sciences,"  January,  1881. 
«  Ibid. 


212  A  TEXT-BOOK  ON  SURGERY, 

In  the  study  of  cases  in  which  one  or  the  other  primitive  carotid  has 
lieen  tied  for  uncomplicated  aortic  aneurism  I  am  enabled  to  collect  but 
nine  instances.  In  the  limits  of  a  text-book  it  will  lie  impossible  to  give  a 
detail  of  such  cases,  however  interesting  to  the  student.  1  refer  him  to  my 
article  on  this  subject  in  the  "  American  Journal  of  the  Medical  Sciences," 
January,  1881.  The  operators  were  Montgomery,  T.  Holmes,  Barwell, 
TiUanus,  Rigen,  O'Shaugnessy,  Annandale,  Heath,  and  Bryant.  Tiie  Uft 
carotid  was  tied  in  six  cases,  and  all  recovered.  Montgomery' s  patient 
died,  four  months  after  operation,  from  purulent  pericarditis.  The  tumor 
had  solidified  and  sloughed.  Holmes's  case  was  much  improved,  and,  in 
answer  to  my  inquiry  concerning  this  case,  in  1880,  five  years  after  the 
operation,  he  w^rites  that  the  patient  is  still  living,  that  there  is  pulsation 
and  bruit  in  the  thoracic  portion  of  the  aneurism,  but  there  is  no  longer 
any  tumor  perceptible  in  the  neck. 

Barwell's  case  was  greatly  relieved,  dying  four  months  later  of  another 
affection.  Tillanus's  operation  was  followed  by  recovery  and  diminution 
of  the  tumor,  dying  suddenly  five  months  later  (probably  from  cerebral 
embolism).  The  sac  was  completely  filled  with  coaguluni.  Rigen  tied 
the  carotid,  February  21,  1829.  The  patient  was  relieved,  and  the  tumor 
diminished  considerably  in  volume.  On  May  9th  was  operated  on  for 
strangulated  hernia,  and  died  June  13th,  as  was  supposed,  from  asthma. 
The  tumor  was  solidified.  In  Heath's  case  the  relief  for  a  long  period 
was  marked  and  undoubted.  The  patient  lived  nearly  four  years,  dying 
ultimately  of  rupture  of  the  sac. 

O'Shaugnessy  tied  the  right  carotid,  with  fatal  rupture  of  the  aneurism 
into  the  mediastinum  on  the  tenth  day.  Annandale  performed  the  same 
operation  with  immediate  relief  and  success.  Mr.  Bryant's  patient  died 
on  the  tenth  day.  The  right  carotid  was  tied,  with  no  effect  on  the 
aneurism.  The  results  in  these  instances  also  lead  me  to  conclude  that, 
in  sacculated  aneurisms  of  the  aorta,  near  the  origin  of  the  innominate 
and  left  carotid,  deligation  of  one  carotid,  especially  the  left,  is  a  justi- 
fiable procedure  when  the  conservative  method  of  rest  and  restricted  diet 
has  failed. 

Aneurism  of  the  thoracic  aorta  beyond  the  transverse  segment  is  not 
amenable  to  surgical  treatment. 

Aneurism  of  the  Innominate  Artery. — The  symptoms  of  this  for- 
midable lesion  have  been  given  on  a  preceding  page.  It  is  frequent- 
ly complicated  with  aneurismal  dilatation  of  the  aorta,  or  of  the 
two  vessels  into  which  it  usually  bifurcates.  It  will  be  interesting 
to  study  the  results  of  operative  procedures  under  the  following  sub- 
divisions : 

1.  Innominate  Anetirism.  2.  Aortic  innominate  Aneurism. — For  in- 
nominate aneurism,  {a)  the  double  simultaneous  distal  ligature  (carotid 
and  third  division  of  the  subclavian)  ;  (h)  the  double  non-simultaneous 
distal  operation  ;  (e)  distal  deligation  of  the  carotid  artery  alone ;  id) 
distal  deligation  of  the  subclavian  artery  alone. 

Si7mdtaneous  Deligation  of  tlie  Rigid  Common  Carotid  and  tJie 
Right  Suhclavian  Artery  {Third  Division)  for  the  Relief  of  Innominate 


SPECIAL  ANEURISMS.  213 

Aneurism* — Prof.  J.  L.  Little  performed  this  operation  in  1877.  The 
patient  recovered,  was  much  improved,  and  died  from  pleuritis,  not  asso- 
ciated with  the  aneurism,  three  years  later.  The  carotid  and  subclavian 
were  slightly  involved.  Dtirham's  patient  died  on  the  sixth  day,  as  was 
reported,  from  "shock."  The  possibility  of  cerebral  embolism  is  worthy 
of  consideration  in  explaining  the  sudden  death  of  this  patient.  M'Car- 
thy's  case  died,  on  the  fifteenth  day,  from  hajmorrhage  on  the  proximal 
side  of  the  subclavian  ligature.  Prof.  Eliot's  patient  died,  on  the  twenty- 
sixth  day,  from  haemorrhage  from  the  sac.  Prof.  L.  A.  Stim  son's  patient 
recovered,  with  marked  improvement  and  consolidation  of  the  aneurism. 
The  tumor  became  very  much  smaller,  and  the  symptoms  were  relieved. 
Death  occurred,  twenty-one  months  after  the  operation,  from  phthisis. 
The  sac  was  filled  with  firm  clot.  In  the  case  operated  upon  by  Prof.  R. 
F.  AV'eir,  death  resulted,  from  rupture  of  the  sac,  on  the  fifteenth  day. 
Rossi's  patient  died  on  the  sixth  day,  most  probably  from  cerebral  anje- 
mia,  since,  at  the  necropsy,  the  left  vertebral  was  the  only  pervious 
artery  leading  to  the  brain.  Ensor's  case  ended  in  death,  from  rupture 
of  the  sac,  on  the  sixty-fifth  day.  Barwell  operated,  with  recovery  and 
marked  improvement.  King's  patient  died,  from  haemorrhage  from  the 
aneurism  near  the  carotid  ligature,  on  the  one  hundred  and  eleventh  day. 
Gerster's  case  recovered,  with  gradual  improvement.f 

Of  these  eleven  cases,  recovery,  -with  a  cure  more  or  less  perfect,  took 
place  in  four,  while  death  occurred  in  seven.  It  is  very  probalile  that,  if 
in  some  of  these  fatal  cases  the  operation  had  been  performed  earlier, 
the  rate  of  mortality  would  have  been  lower. 

The  double  distal  operation,  with  varying  intervals  between  the  deli- 
gation  of  the  carotid  and  the  subclavian  arteries,  has  been  performed  in 
the  following  instances  :  Prof.  A.  B.  Mott  tied  the  subclavian  artery  in  a 
patient  who  had  had  the  right  carotid  deligated  one  year  previously.  The 
patient  died,  three  years  after  the  last  operation,  from  phthisis.  The 
aneurism  was  cured.  In  Heath's  case  the  carotid  was  first  tied,  with  tem- 
porary amelioration  of  symptoms.  Two  years  later  the  siibclavian  was 
operated  upon.  The  aneurismal  bruit  disappeared,  and  the  urgent  symp- 
toms disappeared.  Four  months  later  the  patient  died  fi'om  traumatic 
pleuritis,  caused  by  a  fall  while  drunk.  The  tumor  was  consolidated. 
In  Wickham's  case  the  interval  was  two  months  and  nine  days.  Imme- 
diate and  temporary  relief  followed  both  operations.  Death  ensued  from 
rupture  of  the  sac  on  the  forty-fourth  day.  INIalgaigne's  patient  was  not 
materially  benefited  liy  the  first  operation.  Three  months  later  the 
subclavian  was  tied,  followed  by  death,  from  rupture  of  the  sac,  on  the 
twenty-first  day. 

A  glance  at  these  cases,  and  a  careful  study  of  their  more  complete 
histories,  can  not  but  impress  one  with  the  gravity  of  the  surgical  pro- 
cedure ixnder  consideration.  The  postural,  dietetic,  and  mediciual 
method  should  be  thoroughly  tried  in  all  cases  Mhere  the  disease  has  not 

*  For  more  complete  details,  see  preceding  reference. 
t  "  German  Hospital  Records,"  1883-'8-i,  Xew  York  city. 


214  A  TEXT-BOOK  ON  SURGERY. 

progressed  so  far  that  death  is  imminent  from  pressure,  or  the  sufTering 
so  intense  that  life  becomes  intolerable.  Under  these  last  conditions  the 
operation  is  justifiable.  If  the  conservative  method,  aftei-  n  coiii;ii:pohs 
and  faithl'ul  trial,  does  not  arrest  the  disease,  tlien  again  thn  operation 
is  demanded.  There  is  little  choice  between  the  simultaneous  deligation 
and  the  operation  with  an  interval.  Tlie  carotid  should  always  be  first 
tied,  to  prevent  the  danger  of  cerebral  embolism. 

Innominate  Aneurism  treated  by  Deligation  of  the  Carotid,  or  the 
Suholaviaii.  {The  t<iiifjle  Distal  Cypcrafion.) — The  records  of  surgical 
literature  contain  fourteen  instances  in  which,  for  the  relief  of  aueuiism 
involving  the  innominate  artery  alone,  the  distal  ligature  was  ai)plied  to 
the  right  carotid. 

In  Hutton's  case  death  occurred,  on  the  seventh  day,  from  rupture  of 
the  sac  ;  Neumeister's  on  the  fifth  day,  from  cerebral  complications.  One 
of  Valentine  Mott's  jjatients  died,  from  litBmorrhage  from  the  carotid,  on 
the  twentietli  day.  In  Porta's  case,  which  ended  fatally  in  forty  hours, 
the  sac  was  found  to  have  involved  the  origins  of  the  right  carotid  and 
subclavian  arteries.  A  similar  condition  was  observed  in  the  case  oper- 
ated npon  by  Yilardebo,  wiiich  terminated  fatally  on  the  twenty-first  day. 
Fergusson's  patient  died  on  the  seventh  day.  The  autojjsy  showed  that 
the  origin  of  the  subclavian  was  also  involved.  The  case  by  Butcher 
ended  in  death  on  the  fourth  day.  The  innominate  Avas  the  seat  of  a 
fusiform  dilatation,  while  the  sacculated  aneurism  Avas  found  to  exist  in 
the  third  portion  of  the  subclavian  arteiy.  Holmes  reports  a  case  by 
Ordile,  of  Naples,  which  also  proved  fatal. 

A  case  by  Scott  was  temporarily  benefited,  but  did  not  long  survive, 
dying  from  rupture  of  the  sac.  Nussbaum's  patient  was  not  benefited, 
and  died  from  the  pi'ogress  of  the  disease.  The  case  of  Morrison,  in 
which  the  aneurism  involved  the  origin  of  the  carotid,  recovered,  with 
improvement,  but  died  suddenly  one  year  and  eight  months  later,  after 
prolonged  exertion.  A  second  case  by  V.  Mott  recovered,  with  marked 
temporary  improvement,  but  death  ensued  from  pressure  of  tlie  consoli- 
dated tumor  on  the  trachea.  Pirogoff's  patient  recovered,  improved. 
The  history  of  this  case  ceases  after  two  months  and  a  half. 

In  one  single  instance  (Evans's)  a  cure  was  eS'ected,  and  this  after 
suppuration  occurred  in  the  sac,  which  discharged  twenty-four  ounces 
of  pus. 

Of  the  fourteen  cases,  eight  ended  fatally.  Seven  of  these  died  between 
the  second  and  twenty-first  day,  and  in  one  of  these  it  is  evident  that 
death  was  caused  by  the  consolidation  of  the  aneurism. 

Another  surgical  procedure  for  the  relief  of  innominate  aneurism, 
which  has  received  the  sanction  of  eminent  practitioners,  is  that  of  single 
deligation  of  the  subclavian  artery  in  its  third  division.  The  operators 
are  Wardrop,  Broca,  and  Thomas  Bryant.  Each  case  recovered,  with 
marked  improvement.  Wardrop's  patient  lived  two  years,  and  died 
partly  from  the  effect  of  pressure  of  the  aneurism  and  partly  from  general 
systemic  failure.  The  tumor  was  firmly  solidified,  with  the  exception  of 
a  small  central  channel  which  led  into  the  carotid.     Broca's  case  died, 


SPECIAL  ANEURISMS.  215 

from  pulmonary  gangrene,  five  months  later.  Consolidation  was  also 
almost  complete  in  this  case.  Bryant's  patient  was  living  one  year  after 
the  operation,  and  there  was  evidence  of  solidification  in  the  tumor. 

While  it  is  scarcely  possible  to  base  a  definite  opinion  upon  a  study 
of  such  a  limited  number  of  cases,  the  evidence  seems  to  be  in  favor  of 
the  operation  of  tying  the  subclavian  in  preference  to  the  carotid  for 
innominate  aneurism.  It  would  be  natural  to  infer  that  the  danger  from 
cerebral  embolism  would  be  great  after  such  a  procedure,  yet  it  evidently 
did  not  occur  in  either  of  these  instances. 

Deligation  of  the  right  carotid  alone  is  demonstrated  to  be  so  dangerous 
an  operation  that  I  should  hesitate  to  perform  it  until  all  other  expedients 
had  failed. 

In  aneurism  involving  both  the  innominate  and  the  aortic  arch,  the 
double  distal  operation  is  recorded  in  eight  instances.  In  the  following 
cases  the  two  vessels  were  tied  at  the  same  operation,  excepting  one  in 
which  there  was  an  interval  of  only  twenty-four  hours.  Mr.  Barwell,  in 
one  instance,  with  a  recovery  and  very  great  improvement.  The  patient 
died,  nineteen  months  later,  from  bronchitis.  The  tumor  was  firmly  con- 
solidated. The  same  surgeon,  in  a  second  case  (with  an  interval  of 
twenty-four  hours),  with  recovery  and  great  improvement.  Death  from 
broncho-inieumonia  three  months  later.  The  tumor,  as  large  as  a  tennis- 
ball,  was  solid,  excepting  a  central  globular  cavity  one  inch  in  diameter. 
The  same  surgeon,  in  a  third  case,  which  ended  fatally,  from  asphyxia, 
in  thirty  hours.  Mr.  Holmes's  patient  died  from  exhaustion  two  months 
after  ojieration.  The  sac  was  full  of  recent  clot.  ilr.  Lane's  case  tenni- 
nated  fatally  within  three  months,  from  rupture  of  the  sac.  The  patient 
operated  upon  by  Mr.  Hodges  died,  with  symptoms  of  broncho-pneu- 
monia, on  the  twelfth  day.  There  was  no  sacculated  aneurism,  but  an 
extensive  fusiform  dilatation  of  the  innominate  and  aorta.  Ransohoff's 
case  ended  fatally,  from  asphyxia,  in  seven  days.  In  one  instance  Mr. 
Bickersteth  operated,  with  an  iuterval  of  forty-nine  days,  but  without 
benefit,  as  the  patient  died  from  the  progress  of  the  disease  in  three 
months. 

The  results  in  these  cases  do  not  encourage  a  rej)etition  of  this  opera- 
tion in  well-marked  instances  of  aorto-innominate  aneurism.  The  con- 
servative methods  ofi'er  the  best  hope  of  palliation. 

The  deligation  of  one  of  the  primitive  carotids  has  been  performed  in 
six  instances  for  the  relief  of  aneurism  invt)lving  the  innominate,  comjili- 
cated  with  dilatation  of  the  aorta  or  the  first  portion  of  the  right  sub- 
clavian or  carotid.  Pirogoff  tied  the  left  carotid  in  two  cases.  .  One  died 
within  a  week,  from  hemiplegia  and  coma  ;  the  sac  was  completely  filled 
with  clot.  The  other  recovered,  and  was  improved  up  to  two  months, 
when  the  history  ceases.  In  the  remaining  four  cases  the  right  carotid 
was  tied.  The  operation  by  Hewson  teindnated  fatally  on  the  tenth  day, 
from  asphyxia,  due  to  pressure  from  the  consolidated  tumor.  The  two 
terminal  branches  of  the  innominate  were  also  involved.  Campbell's 
patient  sufl'ered  a  like  fate,  from  the  same  cause,  wlide  Key's  was  also 
fatal  in  foiir  hours,  from  coma.      Hutchison's  died  on  the  forty-first 


216  A  TEXT-BOOK  ON  SURGERY. 

day,  from  asphyxia,  due  to  pressure  of  the  enlarged  and  consolidated 
aneurism. 

Thus,  in  six  cases,  five  died  within  a  few  days  after  the  operation,  and 
three  of  these  seem  to  have  ended  fatally  from  consolidation  of  tlie  aneu- 
rism, the  very  object  for  which  it  was  performed. 

Aneririum  of  tfte  Common  Carotid  Artery. — Aneiirism  of  the  carotid 
may  occur  in  any  part  of  tlie  course  of  this  vessel,  being  in  rare  instances 
intra- thoracic  (when  the  left  trunk  is  involved). 

Tlie  diagnosis  of  aneurism  of  the  left  carotid,  low  down,  depends  upon 
the  presence  of  the  aneurismal  l)ruit  at  the  spot  of  the  tumor,  this  nuir- 
mur  being  carried  along  in  the  distribution  of  the  artery.  Pressure- 
symptoms  are  referalile  to  laryngeal  interference  from  compn^ssioii  upon 
the  pneumogastric  ;  or  distention  of  the  left  internal  jugular,  and  in  rare 
instances  the  left  subclavian  vein.  The  presence  of  the  swelling  is  usu- 
ally first  recognized  in  the  space  between  the  two  tendons  of  origin  of 
the  left  sterno-mastoid  muscle.  Aneurism  of  the  right  carotid,  within 
the  first  inch  of  its  course,  gives  rise  to  the  ordinary  sjTnptoms  of  this 
lesion,  just  beneath  the  sterno-mastoid  muscle,  at  and  immediately  above 
its  clavicular  origin. 

Aneurism  of  the  vertebral  artery,  in  its  lower  portion,  may  be  differ- 
entiated from  that  of  the  carotid  by  compression  of  this  latter  vessel  high 
up.  If  the  thumb  be  placed  over  the  carotid,  at  its  bifurcation,  and 
pressed  firmly  and  directly  backward  against  the  vertebral  column,  such 
compression  will  not  affect  the  circulation  in  the  sac  of  a  vertebral  aneu- 
rism, while  if  involving  the  carotid  it  would  be  visibly  affected.  Then, 
again,  vertebral  aneurism  is,  in  nearly  every  instance,  of  traumatic  origin, 
and  the  traumatism  is  usually  a  stab  wound,  while  aneurism  of  the  carotid 
is  almost  always  idiopathic. 

In  the  differential  diagnosis  of  these  two  lesions  higher  in  the  neck, 
the  same  method  is  applicable.  It  should  not  be  forgotten,  in  tlie  effort 
to  form  a  diagnosis,  that  careless  manipulation  of  a  cervical  aneurism  is 
not  allowable,  on  account  of  the  danger  of  detaching  a  clot,  which  may 
pass  up  into  the  brain.  If  the  tumor  involve  the  carotid  or  its  branches, 
compression  of  the  primitive  trunk,  low  down,  will  aiTest  the  pulsation 
in  the  sac.  This  is  best  accomplished  by  relaxing  the  sterno-mastoid 
muscle  of  that  side,  and  grasping  the  vessel  between  the  thumb  and 
finger  earned  behind  the  muscle.  On  account  of  the  deep  seat  of  the 
vertebral  artery  its  compression  by  this  manoeuvre  is  impossible.  This 
last  vessel  may  be  compressed  by  placing  the  thumb  one  inch  directly 
below  the  transverse  process  of  the  sixth  cervical  vertebra,  and  pressing 
backward.  Above  this  point  it  is  impossible,  since  the  vessel  loins  into 
the  vertebral  foramina. 

The  treatment  of  carotid  aneurism  is  surgical  and  palliative.  The  last 
method  refers  to  the  postural,  dietetic,  and  medicinal  treatment  of  aneu- 
risms in  general.  The  only  surgical  procedure  which  should  be  recom- 
mended is  the  ligature.  While  it  is  true  that  some  cases  are  recorded  as 
cured  by  digital  compression,  I  can  not  but  consider  this  method  as  dan- 
gerous, for  the  reason  that,  in  the  process  of  consolidation  where  the  cir- 


SPECIAL  A]st:ukisms.  217 

culation  is  only  temporarily  interrupted,  cerebral  embolism  may  occur. 
The  animal  ligature,  with  antiseptic  cleanliness,  offers  the  safest  means 
at  our  disposal. 

The  operation  varies  with  the  seat  of  the  tumor.  It  may  be  divided 
into  deligation  upon  the  distal  and  cardiac  side  of  the  aneurism. 

The  distal  ligature  has  been  applied  in  seven  recorded  instances— five 
on  the  right  and  two  on  the  left  carotid.  Two  deaths  occurred  from 
hfemoiThage  ;  one  from  the  distal  side  of  the  (silk)  ligature  on  the  sixty- 
first  day,  the  second  case  fi'om  mpture  of  the  aneurism  on  the  sixty- 
seventh  day.  A  third  case  recovered,  but  the  progress  of  the  disease 
was  not  arrested,  and  death  followed  the  rupture  of  the  sac  on  the  ninety- 
first  day. 

The  remaining  four  cases  were  either  much  improved  or  cured.  The 
use  of  the  catgut  ligature  would  probably  have  saved  the  patient  operated 
upon  by  Lambert,  in  which  sUk  was  used,  causing  death  from  hfemor- 
rhage  on  the  sixty -first  day. 

Deligation  upon  the  cardiac  side  is  always  preferable  when  a  sufficient 
extent  of  sound  artery  can  be  secui-ed  around  which  to  apply  the  ligature. 
In  my  "Essays  on  the  Surgery  and  Anatomy  of  the  Great  Vessels  of  the 
Neck "  I  have  recorded  106  cases  in  which  the  artery  was  tied  on  the 
cardiac  side  of  the  aneurism  ;  69  recovered ;  rate  of  mortality,  35  per  cent. 
For  aneurism  of  the  external  carotid  or  its  bi-anches,  17  recoveries  and  5 
deaths.  Of  the  17  recoveries  16  were  cured.  For  aneurism  involving  the 
common  carotid  alone,  the  death-rate  was  44  per  cent.  "When  the  aneu- 
rism involves  the  common,  external,  and  internal  carotids,  the  ligature 
should  be  applied  to  the  common  trunk,  on  the  cardiac  side,  while  the 
distal  ligature  may  be  applied  to  the  external  trunk,  at  the  same  time 
securing  the  larger  branches  derived  from  this  vessel  between  the  ligature 
and  the  bifurcation.  By  this  operation  the  circulation  through  the 
tumor,  and  in  the  direction  of  the  brain,  is  jaractically  arrested. 

Aneurism  of  the  external  carotid  demands  the  deligation  of  this  vessel 
and  no  other,  when  by  a  careful  dissection  it  is  discovered  that  thei"e  is  a 
half  or  three  quarters  of  an  inch  of  this  trunk  between  the  bifurcation  and 
the  sac.  In  the  event  that  this  method  is  impracticable,  the  common 
trunk  must  be  tied. 

Aneurism  of  the  internal  carotid,  in  the  neck,  should  be  treated  by 
the  deligation  of  this  vessel,  between  the  sac  and  the  common  trunk,  if 
possible.  When  a  sufficient  surface  of  healthy  artery  can  not  be  obtained, 
the  common  and  external  carotids  should  be  tied,  together  with  all 
branches  derived  from  the  external,  on  the  cardiac  side  of  the  ligature. 
I  performed  this  operation  in  one  instance,  resulting  in  the  rapid  and 
permanent  cure  of  a  large  extra-cranial  aneurism  of  the  internal  carotid. 
The  common  trunk  was  first  tied,  with  a  nerve  ligature,  after  which  cat- 
gut was  applied  to  the  superior  thyroid,  and  external  carotid,  just  above 
its  origin. 

Aneurism  of  the  interaal  carotid  may  occur  in  the  cavernous  or  cere- 
bral portions  of  this  vessel.  In  the  petrous  canal  dilatation  is  practically 
impossible.     Not  infrequently  an  arterio-cavernous  aneurism  occurs  from 


218  A  TEXT-BOOK  ON   SURGERY. 

the  giving  way  of  the  septum  between  these  two  vessels.  The  cause  may 
be  traumatic,  as  in  fracture  at  the  base  of  the  skull,  oi-  the  communica- 
tion may  be  established  without  appreciable  cause. 

Tile  symptoms  of  aueurismul  dilatiitiou  here  are  of  two  kinds:  those 
referable  to  pressure  upon  the  brain  and  nerves,  and  those  due  to  inter- 
ference Avith  the  return  venous  current  through  the  ophthalmic  vein.  If 
the  arterio-venous  communication  has  occurred,  exophthalmus  is  marked, 
and  the  eyeball  is  projected  forward  with  each  arterial  pulse.  iSinging 
in  the  ears,  dizziness,  with  varying  loss  of  function  due  to  pressure,  are 
other  symptoms  of  this  condition. 

The  ophthalmic  artery  may  be  the  seat  of  aneurism,  within  the  cranial 
cavity  or  in  the  orbit.  True  sacculated  intra-orbital  aneurism  of  this 
artery  is  extremely  rare,  only  two  cases  being  recorded,*  although  pul- 
sating tumors,  as  arterio-venous  aneurisms,  angeiomata,  cirsoid  arterial 
tumors,  etc.,  are  not  infrequent  in  this  locality.  The  chief  point  in  the 
diagnosis,  and  the  one  whicli  has  an  important  bearing  in  treatment,  is 
compression  of  the  carotid.  If  pulsation  ceases,  and  the  other  symptoms 
disappear,  the  indication  is  direct  that  the  ligature  should  be  applied  to 
this  vessel.  The  common  trunk  should  be  tied,  in  order  to  cut  off  the 
free  communication  between  the  branches  of  the  external  carotid  and  the 
ophthalmic  in  the  orbit.  In  my  Essays  are  given  fifty-two  instances  in 
which  this  operation  was  done  for  pulsating  non-malignant  tumors  of  the 
orbit,  with  a  death-rate  of  11^  per  cent.f  About  T.")  per  cent  of  recoveries 
after  this  operation  result  in  cures.  In  severe  cases  extirpation  may  be 
necessitated. 

Aneurism  of  any  branch  or  branches  of  the  external  carotid  should  be 
treated  by  compression  on  the  cardiac  side,  when  this  is  practicable,  or 
by  the  ligature  of  the  trunk  involved,  or  the  external  trunk. 

Aneurism  of  the  Subdarian  Arteries. — The  subclavian  arteries  may 
be  affected  in  any  portion  of  their  extent,  although,  on  account  of  the 
pressure  exercised  by  the  two  scaleni  muscles,  between  which  their  second 
portion  lies,  this  division  is  less  frequently  involved  in  aneurismal  dilata- 
tion. The  seat  of  this  disease  is  by  preference  in  the  third  portion,  the 
first  division  being  next  in  order.  Exposure  to  violence  or  muscular  effort 
undoubtedly  has  much  to  do  with  the  development  of  subclavian  aneurism, 
since  males  are  very  much  more  frequently  affected  than  females,  while 
the  tumor  is  found  on  the  right  side,  in  the  great  majority  of  cases. 

The  first  portion  of  the  right  subclavian  is  not  infrequently  involved 
in  the  progress  of  an  innominate  aneurism.  Upon  the  left  side  aneurism 
of  the  thoracic  portion  of  this  vessel  is  rare. 

Subclavian  aneurism,  as  it  usually  develops,  is  first  recognized  as  a 
pulsating  tumor,  felt  rather  than  seen  behind  the  clavicle,  and  to  the 
outer  side,  or  behind  the  sterno-mastoid  muscle.  It  may  be  mistaken  for 
a  glandular  or  other  tumor  of  the  softer  tissues.     The  symptoms  which 

*  Prof.  Sattler's  classical  paper  in  Graefe  and  Saemiscli's  "  Handbach  d>^r  gesamrater 
Augeulieilkunde,"  Lcipsic,  1880. 

t  "  Prize  Essays  of  the  American  Medical  Association,  1878,"  William  Wood  &  Co.,  New 
York. 


SPECIAL  AXEURISMS.  219 

have  been  already  detailed  will  serve  as  a  guide  to  proper  differentiation. 
Difficulty  may  arise,  even  after  the  aneurismal  character  of  the  swelling 
has  been  recognized,  in  determining  from  what  vessel  the  tnnior  springs. 
As  has  been  said,  the  progress  of  aortic  aneurism  gives  rise  to  pulsation 
and  pressure  symptoms,  located  in  the  thorax  for  a  considerable  period 
prior  to  tlie  approach  or  ajipearance  of  the  tumor  at  the  root  of  the  neck. 
In  fact,  aneurism  of  the  aorta,  in  many  instances,  produces  death  before 
it  attains  such  magnitude.  On  the  right  side,  this  knowledge  will  aid 
materially  in  recognizing  the  seat  of  the  lesion,  and.  fortunately,  aneu- 
rism of  the  arch  and  subclavian  occurs  most  often  on  this  side  of  the 
body.  The  differentiation  of  aneurism  of  the  thoracic  portion  of  the  left 
artery,  from  the  same  lesion  of  the  arch,  near  the  origin  of  the  subclavian, 
is  somewhat  more  difficult.  When  the  tumor  involves  the  subclavian  its 
appearance  in  the  neck  is  more  rapid  than  in  aortic  aneurism,  while  in- 
terference with  the  return  circulation  in  the  ann,  which  may  appear  early 
in  the  history  of  subclavian  aneurLsm,  is  rare  when  the  aorta  is  the  seat 
of  this  lesion.  Again,  in  aneurism  of  the  second  or  third  portion  of  the 
arch,  which  does  not  involve  the  subclavian,  the  pulse-wave  in  the  left 
radial  wiU  be  of  equal  force  and  synchronous  -n-ith  that  of  the  right  side. 

The  treatment  of  subclavian  aneurism  is  a  subject  of  great  importance, 
and  one  which,  from  a  study  of  a  number  of  cases,  has  led  to  great  diver- 
sity of  opinion  and  practice. 

The  methods  may  be  divided  into  the  surgical ;  the  postural,  medical, 
and  dietetic  ;  and  the  palliative  or  expectant.  The  employment  of  any 
of  these  means  will,  again,  be  in  great  part  determined  by  the  portion  of 
the  artery  involved  in  the  disease.  The  surgical  ti-eatment  comprises  the 
ligature  on  the  cardiac  or  distal  side  ;  compression  on  the  distal  side,  or 
applied  directly  to  the  sac  ;  and  massage. 

The  innominate  artery  has  been  tied  on  account  of  subclavian  aneu- 
rism seventeen  times  with  sixteen  deaths. 

The  operators  and  results  were  as  follows :  Y.  Mott,  died  twenty-sixth 
day,  haemorrhage  from  distal  side.  Graef e,  died  sixty-seventh  day,  hjemor- 
rhage  fi-om  distal  side  of  ligature.  Xonnan,  died  thu'd  day,  hfemorrhage. 
Arendt,  eighth  day,  pneumonia.  Hall,  fifth  day,  exhaustion  and  venesec- 
tion. Bland,  eighteenth  day,  haemorrhage  from  distal  side  of  ligature. 
Lizars.  twenty-second  day,  h^emorrliage  from  distal  side.  Gore,  seven- 
teenth day,  hfemorrhage  from  cardiac  side  of  ligature.  Cooper,  eighth  day. 
Cooper,  thirty-fourth  day,  hemorrhage.  Pirogoff,  two  days,  pneumonia. 
A.  B.  Mott,  twenty-third  day,  haemorrhage,  sac  burst  into  pleiira.  Bick- 
ersteth,  sixth  day,  hfemorrhage  from  distal  side  of  ligature.  Thomson, 
forty-second  day,  hsemorrhage  from  distal  side  of  ligature.  Smyth,  recov- 
ered, after  ligature  of  innominate  and  carotid  at  first  operation,  and  the 
vertebral  fifty-four  days  later,  to  arrest  violent  bleeding.  This  patient 
died,  ten  years  later,  from  haemorrhage  from  the  sac  of  the  old  aneurism. 
Thomson,  died  forty-second  day,  exhaustion  from  repeated  ha?morrhage 
from  distal  side  of  ligature.  Bull,  thirty-third  day,  haemorrhage  from 
proximal  side  of  ligature  on  thirtieth  and  thirty-third  days  ;  right  carotid 
and  vertebral  also  tied  at  same  time  with  the  innominate. 


220  A  TEXT-BOOK  ON  SURGERY. 

Tlie  subclavian  artery  has  been  tied  in  its  first  siirgical  division  for 
the  relief  of  aneurism  involving  this  vessel,  or  its  third  portion,  conjointly 
with  the  first  part  of  the  axillaiy  (siibclavio-axillary),  in  the  following 
instances :  Culles,  death  on  fourth  day,  from  haMuorrhage  at  seat  of  liga- 
ture. Y.  Mott,  death  on  eighteenth  day,  haemorrhage.  Bayer,  death 
in  twenty-four  hours,  from  bursting  of  sac.  Ilayden,  death  on  twelfth 
day,  from  hjemorrhajje  at  seat  of  ligature.  O'Reilly,  death  on  thirteenth 
day,  hfemorrhage.  Partridge,  death  on  fourth  day,  pericarditis,  pleuritis, 
pj'ajmia.  Liston,  death  on  thirty-sixth  day,  hfemorrhage  from  distal  side. 
Rodgers,  death  on  fifteenth  day,  hamiorrhage  from  distal  side  of  ligature. 
Auvert,  death  on  eleventh  day,  h;eniorrhage,  distal  side.  Auvert,  death 
on  twenty-second  day,  luemorrhage  from  distal  side.  Liston,  death  on 
thirteenth  day,  hjemorrhage  (right  carotid  tied  at  same  time).  Parker, 
death  on  forty-second  day,  haemorrhage  from  distal  side  of  ligature  (right 
carotid  tied  at  same  operation).  Of  these  twelve  cases  all  died  soon  after 
the  ligature.     Only  in  one  case  (Rodgers)  was  the  left  subclavian  tied. 

For  subclavian  or  subclavio-axiUary  aneurism  the  ligature  has  been 
applied  in  the  second  portion  in  four  cases.  Liston,  death  on  fourteenth 
day,  haemorrhage  at  seat  of  ligature.  Nichols,  recovered,  cured.  Au- 
chincloss,  death  on  third  day,  from  cerebral  complications.  AVarren, 
recovered,  cured.  Gay,  death  on  ninth  day,  bronchitis  and  pneumonia. 
Giving  four  cases,  with  two  deaths  and  two  cures. 

Deligation  of  the  subclavian  artery,  in  its  thii-d  portion,  for  subclavio- 
axillary  or  axillary  aneiirism,  has  been  performed  one  hundred  and  thir- 
teen times,  with  forty-seven  deaths.*  Naturally  the  mortality  is  greater 
in  proportion  to  the  jiroximity  of  the  aneurism  to  the  heart  and  to  the 
seat  of  the  ligature.  Thus,  in  thirty-four  of  these  cases  the  disease  in- 
volved the  third  portion  of  the  subclavian  or  the  axillary,  or  both  (prop- 
erly named  subclavio-axillary  aneurism).  As  a  result  of  the  operation 
exactly  one  half  perished.  Of  the  seventeen  i-ecoveries,  thirteen  are  re- 
ported cured. 

For  aneurism  of  the  axillary  proper  I  have  the  histories  of  seventy- 
nine  cases  in  which  the  ligature  has  been  applied  to  the  third  portion  of 
the  subclavian,  with  thirty  deaths,  forty-nine  recoveries,  and  forty-six  of 
these  reported  as  cured.  In  seven  of  the  fatal  cases  the  aneurism  was 
traumatic,  and  resulted  from  gunshot  wounds  (six  in  military,  one  in 
civil  practice). 

The  value  of  the  expectant  plan  may  be  estimated  in  the  following 
cases : 

Stnopsis  of  22  Cases  of  Sfbclavian  Axecrism  ix  which  "  no 
Treatment"  was  undertaken. 

IS  deaths,  ^  spontaneous  ctires. 

Eighteen  fatal  cases.  Dates  of  death  after  tumor  was  noticed  (and 
when  surgical  interference  might  have  been  undertaken). 

*  x\.uthor's  Essays,  already  cited. 


SPECIAL  ANEURISMS.  221 

1  case.  Aneurism  had  existed  for  "  some  time."  Died  twelve  weeks  after  admis- 
sion to  liosjjital. 

1  case.     Not  known  how  long  aneurism  had  existed. 

1  case.  Lived  "  some  months."  Died  of  exhaustion  and  suppuration  caused  by- 
pressure  of  sac. 

1  case.     Died  of  rupture  of  sac  twenty-four  years  after  recognition  of  aneurism. 

1  case.     Died  from  asphyxia  caused  by  pressure  of  sac,  eight  years. 

1  case.  Died  from  external  rupture  of  sac  two  years  and  eight  months  after  recog- 
nition of  aneurism. 

1  case.     Died  from  exhaustion  from  pressure  of  sac,  two  years  after  recognition. 

1  case.     Died  from  dyspnrea  from  pressure  of  sac,  two  years  after  recognition. 

1  case.  Died  from  dyspncea  and  exhaustion  from  pressure  of  sac,  one  year  and  a 
half  after  recognition. 

1  case.     Died  from  rupture  of  sac  into  lungs,  one  year  and  a  half  after  recognition. 

1  case.  Died  from  rupture  of  sac  into  lungs  eight  months  and  a  half  after  recog- 
nition. 

1  case.  Died  from  rupture  of  sac  into  tissues,  becoming  diffused,  and  causing  death 
by  pressure,  five  months  and  a  half  after  recognition. 

1  case.     Died  from  rupture  of  sac,  death  by  pressure,  live  months  after  recognition. 

1  case.  Died  suddenly  (probably  from  cerebral  clot)  one  year  and  a  half  after 
recognition. 

1  case.     Died  suddenly,  cause  not  stated,  not  rupture  of  sac. 

2  cases.   Died  from  rupture  of  popliteal  aneurisms. 

1  case.     Died  from  typhoid  pneumonia,  three  years  after  recognition. 

Of  the  four  cures,  three  remained  well ;  one  died  about  f(.)ur  years 
later  from  rujiture  of  an  aortic  aneurism.  Of  these  eighteen  fatal  cases 
in  which  no  treatment  was  undertaken,  three  died  of  other  disease  than 
the  aneurism. 

Of  the  thirteen  cases  in  which  the  duration  of  life  is  noted  after  the 
recognition  of  the  aneurism,  the  sum  total  is  forty-seven  years  and  nine 
months. 

The  sum  of  life  in  the  thirteen  cases  after  deligation  of  the  innominate 
is  about  eight  months,  a  difference  in  favor  of  non-interference  (in  an 
equal  number  of  cases)  of  about  forty-seven  years  of  life. 

Synopsis  of  14  Cases  treated  by  Valsalva's  Method. 
{More  or  less  modified. ) 

1  case.  M.  ;  R.  Subclavian  aneurism.  Size,  hen's  egg.  Venesection  ;  cold  and 
lead  lotion  locally.  Recovered.  Two  and  a  half  years  later  was  work- 
ing as  a  carter  in  the  city. 

1  case.  M.  ;  R.  Subclavian.  Immense  size.  Venesection.  Cold  and  astringents 
locally.  Tumor  reduced  in  size  and  firmer  ;  lost  sight  of  while  in  pro- 
cess of  cure. 

1  case.  M.  ;  R.  Subclavian  (syphilitic).  Valsalva's  method  and  antisyphilitics. 
Cure  complete. 

1  case.  M.  ;  R. ;  age  forty-five.  Subclavian  (sy])hilitic).  Valsalva's  method  and 
antisyphilitics.     Cured  and  seen  well  six  years  later. 


000  A  TEXT-BOOK   OX  SURGERY. 

1  case.  M.  ;  age  forty-two.     Subclavian.    Venesectiou.    Digitalis.    Rest.     Marked 

improvement,  so  tliat  patient  left  hospital  and  was  lost  sight  of. 

1  case.  M.  ;  age  fifty.  Subclavian.  Was  treated  for  an  intercurrent  attack  of 
rheumatism  by  rest,  strict  diet,  and  antiplilogislics.     Cured. 

1  case.  M.  ;  age  thirty-nine.  Subelavio-axillary  (Pancoast's  case).  Valsalva's 
method  had  been  tried  and  considered  a  failure.  Operation  determined 
on.  Carried  into  operating-room.  Patient  fell  into  collapse  and  opera- 
tion was  jiostponed.  Recovered  cured.  (It  is  staled  that  a  large  dose 
of  aconite  had  been  given  by  mistake  just  before  the  operation  was  to 
have  taken  place.) 

1  case.  M.  ;  age  thirty-seven.  Subclavian.  Venesection.  Valsalva's  method  and 
careful  and  persistent  direct  compression  for  one  year  and  a  half.    Cured. 

1  case.  M.  ;  age  fifty-one.  Subelavio-axillary  (by  Pelletan).  Valsalva's  method. 
Cured. 

5  cases  treated  by  this  method  (in  part)  were  fatal.  Venesection  was  not  practiced 
except  in  one  case.  Only  local  and  constitutional  treatment.  All  died 
within  twelve  months  of  the  recorded  recognition  of  the  disease  ;  one 
from  ulceration  into  trachea,  hasmoptysis,  and  exhaustion  ;  two  from 
external  bursting  of  sac  ;  two  from  exhaustion  and  coma  (with  pressure 
on  the  trachea  in  one  case). 

Summar//. — Fourteen  cases.  Cured,  seven  ;  improved,  and  in  process 
of  cure  when  lost  sight  of,  two  ;  died,  live.  No  venesection  in  four  of 
live  fatal  cases.     One  successful  case  modified  by  direct  pressure. 

Syxopsis  of  6  Cases  treated  by  Direct  Pressure  rpox  the 
Sao  (Modifications  givex). 

(All  subclavian  aneurism.) 

1  case.  M. ;  forty-six  years  ;  R.  Leather  "cup"  molded  over  tumor  and  held  in 
place  by  figure-of-8  straps  around  shoulders  and  axilla.  Cured  in  four- 
teen months.  Did  light  work  during  treatment,  and  had  no  other  medi- 
cation. 

1  case.  M.  ;  thirty-nine  years  ;  L.  Enormous  size.  Treated  by  cold  and  pressure 
"  in  turns."  Small  cannon-ball  suspended  so  as  to  press  comfortably. 
Discharged  relieved.  Some  months  later  violent  inflammation  (from 
fall),  sup])uration,  rupture  of  sac  ;  discharged  two  quarts  of  pus  and 
blood.     Cured.     Debility  of  arm  probably  permanent. 

1  case.  M.  ;  forty-one  years.  (Thirteen  months'  duration.)  Kept  in  bed,  on  back  ; 
ice  locally  ;  restricted  diet.  Third  day  air-cushion  for  twelve  hours, 
with  intermissions  amounting  to  three  hours.  Every  half-hour  interval 
of  ice.  Treatment  for  seven  days.  Tumor  began  to  subside,  and  was 
cured  in  twelve  mouths. 

1  case.  (T.  Holmes.)  ("Lancet,"  February  12, 1876,  p.  237.)  Subclavian.  Treated 
by  direct  pressure  from  rubber-ball.     Cured. 

1  case.  (Dupuytren.)     Direct  pressure.     Resulted  fatally. 

1  case.  (Porter.)  Exposed  axillary  and  passed  needle  under  it.  Thirty-five  days 
later  exposed  innominate  and  passed  the  "  acupressure  needle  "  under  it. 
Died  from  haemorrhage  from  innominate  on  tenth  day. 


SPECIAL  ANEURISMS.  223 

(In  one  case  given  in  preceding  table,  direct  pressure  was  practiced 
with  Valsalva's  method.) 

Summanj. — Five  cases  of  ''direct  j)ressure"  (without  operative  pro- 
cedures).    Cured,  four ;  died,  one. 

Synopsis  of  Cases  of  Massage  or  Kxeadixg  ix  the  Treatment  of 

Subclavian  Aneuris-ai. 

Of  this  method  there  are  six  cases. 

Three  cured  ;  viz.,  by  Fergusson,  Little,  and  Porter. 
Three  died  ;  viz.,  by  Fergusson,  Hilton,  and  Morgan. 

(See  '•  Guy's  Hospital  Reports,"  vol.  xvi,  p.  42  et  seq.) 

In  addition,  Mr.  Bryant,  in  his  "  Practice  of  Surgery,"  p.  190,  gives  a 
case  by  Dutoit,  of  Berne,  in  which  a  subclavian  aneiuism  was  cured  by  in- 
jection of  ergotin  around  the  sac  under  the  skin,  and  digital  compression. 

Poland  cured  one  case  by  digital  pressure  on  cardiac  side.  A  third  case 
was  tried  for  forty-six  hours  and  abandoned  on  account  of  pain  from  press- 
ure. The  i:)atient  died  from  exhaustion.  Paget  tried  mechanical  pressure 
in  a  fourth  case,  but  abandoned  it  as  a  hopeless  undertaking.  A  fifth  case 
by  Verneuil  was  improved,  but  lost  sight  of  before  a  cure  was  effected. 

From  the  stiidy  of  the  foregoing  history  of  subclavian,  subclavio- 
axillary,  and  axillary  aneurism,  I  have  reached  the  following  conclusions  : 

Deligation  of  the  innominate  artery,  or  the  subclavian  in  its  first  sur- 
gical division,  are  operations  so  dangerous  that  they  should  be  under- 
taken onh^  in  extreme  conditions. 

The  first  indication  in  the  treatment  of  these  lesions  is  pressure,  judi- 
ciously applied.  If  possible,  the  compres.sion  should  be  exercised  be- 
tween the  tumor  and  the  heart.  Next  in  preference,  direct  pressure  upon 
the  body  of  the  aneurism.  Perfect  and  persistent  rest  should  be  enforced, 
and  with  this  the  method  of  Tuflnel  offers  the  surest  and  safest  means  of 
l)alliation  and  cure. 

In  making  direct  compression,  the  elastic  ball  introduced  by  Mr. 
Holmes  seems  best  adapted.  This  should  be  applied  gradually,  in  order 
to  accustom  the  patient  to  its  presence.  Massage  is  so  inferior  to  the 
plan  just  detailed  that  it  may  be  omitted  from  practice. 

Should  all  these  means  fail  after  a  persistent  trial,  should  the  sac  by 
Tilcerati(m  open  and  threaten  instantaneous  death,  or  should  the  surgeon, 
from  the  appearances,  judge  that  this  accident  was  on  the  eve  of  occur- 
ring, ligature  of  the  innominate  should  be  perfonned,  provided  that  the 
ligature  could  not  be  applied  to  the  subclavian  proper. 

"When  the  aneurism  involves  the  last  portion  of  the  subclavian  or  the 
axillary,  the  ligature  may  be  applied  to  the  third  division  of  the  sub- 
clavian. Compression  should  always  be  tried  in  these,  as  in  all  other 
cases,  before  resorting  to  the  ligature. 

Aneurism  of  the  brachial,  radial,  and  ulnar  arteries,  or  their  branches, 
is  comparatively  rare,  and  when  seen  is  almost  always  the  result  of  a 
wound.  Tlie  diagnosis  is  not  difficult.  The  treatment  required  is  digital 
or  mechanical  coraj)ression  on  the  cardiac  side  of  the  tumor.     If  this  fail, 


224  A  TEXT-BOOK  ON  SURGERY. 

direct  compression  of  the  sac  may  be  added,  and,  if  a  thorough  trial  of 
these  two  methods  is  not  successful,  a  catgut  ligature  should  be  api)lied, 
after  the  method  of  Hunter. 

Aneurism  of  the  Vertebral  Artery. — Aneurism  of  the  vertebral  is 
almost  always  the  result  of  a  punctured  wound.  A  rare  exception  to  this 
rule  is  the  case  of  idiopathic  aneurism  of  both  vertebrals  reported  by  Dr. 
Anderton,  of  New  York  city.*  It  occurs  most  frequently  in  tliat  portion 
of  the  vessel  between  the  atlas  and  the  transverse  ]3rocess  of  the  sixth 
cervical.  The  chief  point  in  diagnosis  is  the  diifereritiation  between  the 
lesion  in  question  and  carotid  aneurism. 

The  difficulty  of  distinguishing  vertebral  from  carotid  aneurism  in  the 
neck  arises  from  the  fact  that  direct  pressure  from  before  backward,  in 
the  lower  portion  of  the  neck,  will  interfere  with  or  aiTest  pulsation  in 
aneurisms  of  both  vessels. 

If,  however,  the  head  be  flexed  upon  the  chest,  and  the  sterno-mastoid 
muscle  thus  relaxed,  the  carotid  can  be  compressed  by  grasping  the  mus- 
cle between  the  thumb  and  linger,  which  are  pressed  deeply  behind  the 
outer  and  inner  borders.     This  will  not  involve  the  vertebral. 

Again,  if  the  carotid  be  forcibly  compressed  by  the  thumb,  backward 
and  inward,  against  the  vertebral  column,  at  any  point  above  the  trans- 
verse process  of  the  sixth  cervical,  the  vertebral  will  not  be  included, 
since  it  is  protected  by  the  processes. 

In  my  Essays  are  recorded  five  cases  in  which  the  common  carotid  was 
tied  for  supposed  carotid,  but  in  reality  vertebral,  aneurism.  All  ended 
fatally. 

In  the  treatment  of  this  lesion  direct  pressure  may  be  employed,  since 
prolonged  compression  of  the  artery  before  it  enters  the  foramen  in  the 
sixth  transverse  process  is  impossible.  One  successful  result  of  this 
method  is  recorded.  If  the  disease  continues  to  increase,  deligaticm  of 
the  vessel  in  its  first  portion  may  be  effected.  This  is  a  very  difficult 
operation,  and  has  rarely  been  attempted.  The  only  operators  so  far  are 
Smyth,  Parker,  Alexander,  and  myself. 

Aneurism  of  the  internal  mammary,  and  other  smaller  branches  of 
the  subclavian,  does  not  demand  separate  consideration.  Aneurism  of 
the  intercostal  arteries  occurs  in  rare  instances,  usually  as  a  result  of 
fracture  of  a  rib  or  a  stab-wound. 

Aneurism  of  the  Abdominal  Aorta. — Aneurismal  dilatation  of  this 
section  of  the  aorta  occurs  most  frequently  near  the  diaphragm.  The 
entire  vessel  may  be  the  seat  of  fusiform  aneurism.  Females  are  less 
frequently  attacked  than  the  opposite  sex.  In  corpulent  perscras  the 
diagnosis  is  dilficult.  Tumors  of  the  central  organs,  as  the  stomach,  pan- 
creas, transverse  colon,  and  the  superjacent  mesentery,  may  be  mistaken 
for  aneurism.  On  the  other  hand,  in  emaciated  persons,  unnatural  ex- 
pansion of  the  aorta  duiing  the  cardiac  systole  has  led  to  a  mistake  in 
diagnosis.  The  history  of  the  development  of  the  tumor,  the  presence  of 
the  aneurismal  tremor  and  bruit,  and  the  recognized  general  exi)ansion  of 

*  "  Medical  Record,"  vol.  xx,  p.  354. 


SPECIAL   ANEURISMS. 


225 


the  sac,  with  the  arterial  pulse,  will  enable  the  careful  observer  to  arrive 
at  a  correct  diagnosis. 

The  Treatment  is  chiefly  expectant.  The  method  of  Tuffuel,  combined 
^vith  interrupted  compression  by  means  of  the  tourniquet,  should  be  em- 
ployed. Pressure  may  be  cardiac,  direct,  or  distal,  the  former  being 
preferable,  if  the  location  of  the  tumor  renders  it  possible.  If  operative 
interference  is  demanded,  the  introduction  of  juniperized  catgut  ligatures 
through  the  canula,  heretofore  described,  would  be  advisable.  Anaesthesia 
is  required,  and  the  duration  of  compression  may  vary  from  fifteen  min- 
utes to  one  hour.  Deligation  of  the  aorta  for  aneurism  of  the  same  is 
scarcely  possible. 

Aneurism  of  the  BrancJies  of  f Tie  Ahdominal  Aorta. — Aneurism  of 
any  of  the  visceral  or  jjarietai  branches  of  the  abdominal  aorta  may  occur. 
The  location  of  the  tumor  and  the  characteristic  symptoms  of  aneurism 
will  point  to  the  vessel  affected.  When  ti-eatment  is  necessarj-,  the  same 
method  should  be  employed  as  for  aneurism  of  the  main  trunk.  Explo- 
ration under  strict  antisepsis  may  be  made,  and  deligation  with  the  ani- 
mal ligature  practiced,  if  the  tumor  is  sufficiently  removed  from  the  aorta 
to  allow  the  application  of  the  ligature  to  non-diseased  tissue. 

Aneurism  of  the  Iliac  Arteries. — Aneurism  of  the  common,  external,  or 
internal  iliac  arteries  is,  fortunately,  of  rare  occurrence.  The  diagnosis  may 
be  made  by  a  study  of  the  history  of  the  individual  case,  and  by  abdomi- 
nal palpation,  coupled  with  physical  exploration  by  the  rectum  or  vagina. 

In  the  treatment  of  aneurism  of  the  common  iliac,  compression  of  the 
abdominal  aorta  should  be  faithfully  tried.  With  this  may  be  combined 
the  treatment  by  rest  and  restricted  diet,  and  carefully  graduated  direct 
pressure.  Should  these  methods  prove  useless,  and  death  be  imminent  from 
rapid  expansion  and  threatened  rupture  of  the  sac,  deligation  of  the  abdom- 
inal aorta  may  be  performed,  or  the  external  iliac  or  femoral  may  be  tied. 

The  abdominal  aorta  has  been  tied  in  the  following  cases  of  iliac 


aneurism : 


.  * 


No. 

Operator. 

Date. 

Bex. 

Age. 

Kesnlt. 

1 

Astlcy  Cooper. 

1817 

M. 

38 

Died  in  forty  hours.  Ligature  applied  three  fourths  of  an  inch 
above  bifurcation  of  aorta.  Tumor  measured  eight  inches  in 
long  axis. 

2 

James 

1829 

M. 

44 

Died  in  three  and  one  half  hours.  Femoral  tied  thirty-three  days 
before  aorta.  Tumor  increased  in  size  and  aorta  tied.  Liga- 
ture applied  seven  ei^iiths  of  an  inch  above  bifurcation. 

3 

Murray 

1834 

M. 

33 

Died  in  twenty-three  hours.  Tumor  extended  as  high  as  the 
unibilieiis.  External  iliac  involved.  Gangrene  was  tlireat- 
cned.     Ligature  half  an  inch  above  bifurcation. 

4 

Monteiro 

1842 

M. 

31 

Died  in  ten  days.  Large  diffuse  aneurism  of  femoral.  Aorta 
ulcerated  at  seat  of  liL'ature,  and  death  took  place  from 
haemorrhaire. 

5 

South  

1856 

H. 

28 

Died  in  fortv-three  hours.     External  and  common  iliac  involved. 

6 

McGuire 

1868 

M. 

30 

Died  in  eleven  hours.  Sac,  which  involved  hoth  common  iliacs. 
burst  during  operation,  when  a  hasty  ligature  was  thrown 
around  the  aorta. 

7 

Watson 

1869 

M. 

? 

Died  in  sixty-five  hours.  Xinc  weeks  after  ligature  of  common 
iliac  h»morrh:i2;e  occurred,  when  aorta,  external  and  inteinal 
iliacs  were  tied.     No  haemorrhage  after  operation. 

8 

Stokes 

1869 

M. 

60 

Died  in  twelve  hours.  Right  common  and  external  iliac  and 
femoral  involved. 

16 


*  Gross's  "  System  of  Surgery." 


22  fi  A  TEXT-BOOK   ON  SURGERY. 

When  the  aneurism  is  located  upon  the  external  iliac,  compression 
witli  the  tourniquet  may  be  employed  over  the  aorta  or  common  iliac 
artei'v.  Prof,  ^^ands  has  advised  and  ])i'acticpd  digital  ])i'essure  of  the 
common  iliac  by  means  of  the  hand  introduced  into  tlie  rectum.  Pressure 
from  within  the  rectum  may  also  be  accomplished  by  means  of  a  bougie 
or  jnece  of  wood  projierly  padded  (Davy's  method).  As  a  last  resort  the 
common  iliac  may  be  tied.  Tliis  operation,  though  dangerous,  has  been 
successfully  accomplished  in  several  instances  in  late  years.  A  patient 
recently  operated  upon  by  Dr.  Lange,  of  New  York,  recovered  and  was 
cured.  Aneunsm  of  the  internal  trunk  is  amenable  to  treatment  by  com- 
pression of  the  aorta  or  common  iliac,  or  by  deligation  of  the  primitive 
trunk. 

Aneurism  of  the  branches  of  this  vessel  usually  occurs  in  the  gluteal 
and  sciatic.  The  origin  is  almost  invariably  traumatic.  The  earliest 
symptoms  are  referable  to  the  presence  of  the  tumor.  It  must  be  distin- 
guished from  abscess  or  hernia.  Aspiration  would  determine  the  ]irospnce 
of  the  former,  and  the  s}'m})toms  of  hernia,  with  absence  of  pidsatiou, 
would  indicate  the  escape  of  the  viscera  through  the  great  sciatic  fora- 
men. The  treatment  is  difficult  and  often  ineffectual.  Direct  compres- 
sion sliould  1)6  tirst  tried.  Incision  into  the  sac,  turning  out  the  clot,  and 
tying  both  ends,  has  been  successful  in  four  of  six  cases  reported  by 
Fischer.  The  ligature  may  also  be  ap])lied  between  the  sac  and  the  point 
of  exit  of  the  artery,  or,  as  a  last  effort,  the  common  iliac  may  be  tied. 

Aneurism  of  the  Femoral  Arteries. — Aneurism  of  the  superficial 
femoral  artery  is  comparatively  frequent.  It  occurs  by  preference  in 
the  upper  half  of  the  artery,  and  in  males  in  the  great  majority  of  in- 
stances.    In  rare  instances  the  disease  is  symmetrical. 

The  diagnosis  is  not  difficult,  since  the  expansile  pulsaticm  of  the 
tumor  can,  in  most  cases,  be  readily  appreciated  by  palpation.  A  tumor 
in  the  line  of  the  artery,  with  the  characteristic  pulsation,  tremor,  and 
murmur,  all  of  which  signs  disappear  when  the  iliac  artery  or  aorta  is 
tirmly  compressed,  point  almost  unerringly  to  a  diagnosis.  The  greatest 
danger  of  error  lies  in  the  presence  of  an  abscess.  Abscess  is,  however, 
of  rare  occurrence  in  this  region,  except  as  a  sequence  of  spinal  caries  or 
hip-joint  disease,  and  these  conditions,  existing  with  the  other  common 
symptoms  of  the  development  of  abscess,  would  lead  to  its  recognition. 
If  doubt  should  still  exist,  after  even  the  most  careful  survey  of  the  case, 
the  hypodermic  needle  would  settle  the  diagnosis. 

Treatment. — Aneurism  of  iive  femoral  artery  will,  in  the  vast  majority 
of  cases,  yield  to  judicious  and  patient  compression.  When  the  tumor 
extends  as  high  as  Poupart's  ligament,  or  above  this  point,  the  chances 
of  success  are  diminished,  since  pressure  will  have  to  be  ai)plied  to  the 
common  or  external  iliac  or  the  aorta.  Under  such  conditions  direct 
compression,  by  means  of  Holmes's  elastic  ball,  applied  so  gradually  that 
inflammation  of  the  sac  will  not  be  precipitated,  should  be  first  faithfully 
tried.  Ligature  of  the  common  or  external  iliac  should  be  deferred  until 
all  other  remedies  have  failed,  and,  when  there  is  a  choice  between  these 
two  procedures,  the  deligation  of  the  external  iliac  should  be  preferred, 


SPECIAL  ANEURISMS.  227 

on  account  of  the  anastomoses  of  the  branches  of  the  internal  iliac  with 
the  vessels  of  the  thigh.  Direct  compression  of  the  sac  was  once  success- 
fully practiced  by  Dr.  Brown,  of  Boston,  in  a  case  of  femoral  aneurism 
at  Poupart's  ligament.  The  weight  employed  may  be  as  much  as  twelve 
pounds.  Iron  balls  were  used  in  this  ca.se.  The  patient  was  confined 
to  bed  for  ten  months.  When  the  tumor  is  so  far  away  fi'om  Poupart's 
ligament  that  digital  or  mechanical  compression  of  the  fem(jral  upon 
the  OS  pubis  is  possible,  this  treatment  should  be  adopted.  Extreme 
tiexion  of  the  thigh  upon  the  abdomen  has  succeeded  in  producing  a  cure 
in  a  few  instances.  Direct  pre.ssure  upon  the  tumor,  with  the  limb  ex- 
tended, is  less  painful  and  equally  efficacious.  When  the  necessity  for 
the  application  of  the  ligature  occurs,  the  effort  .should  be  made  to  reach 
the  artery  below  the  origin  of  i\\^  profunda  femor is,  since  the  danger  of 
gangrene  is  much  less  if  this  great  collateral  route  is  open. 

The  treatment  of  aneurism  of  the  lower  portion  of  the  femoral  does 
not  matei'ially  differ  from  the  above. 

Aneurism  of  the  profunda  femoris  is  rare,  occurring  usually  as  a 
comi)lication  of  this  condition  in  the  common  trunk,  or  as  a  result  of  a 
punctured  wound. 

The  treatment  will  include  pressure  on  the  cardiac  side,  or  direct 
compression,  and,  as  a  last  resort,  ligature  of  the  common  femoral, 
or  iliac. 

Aneurism  of  the  Popliteal  Artery . — About  one  fourth  of  all  aneurisms 
occur  in  this  vessel.  Subjected,  by  reason  of  its  unfortunate  location,  to 
the  accidents  of  compression  in  extreme  flexion  of  the  leg,  it  frequently 
suffers  those  pathological  changes  which  end  in  aneurismal  dilatation, 
and  is  only  second  in  order  of  frequency  to  the  aortic  arch,  which  yields 
to  the  violence  of  the  cardiac  systole.  As  with  aneurism  in  other  loca- 
tions, it  occtirs  most  frequently  in  males,  and  in  the  active  period  of  life, 
being  rare  in  childhood  and  youth,  and  most  common  in  the  years  from 
twenty-five  to  fifty. 

Diagnosis. — On  account  of  the  infrequency  of  tumors  in  this  region, 
other  than  aneurism,  the  diagnosis  is  not  difficult.  The  characteristic 
symptoms  of  this  malady  will  determine  its  differentiation  from  glandular 
enlargements,  exostoses,  over-distended  bursee,  or  abscess. 

Treatment. — In  the  treatment  of  popliteal  aneurism  the  patient  should 
be  placed  in  the  recumbent  posture,  with  the  leg  of  the  affected  side 
slightly  flexed.  A  soft  mattress  should  be  used,  and  the  thigh  and  leg 
held  in  a  comfortable  and  fixed  position  by  means  of  a  pillow  under  the 
popliteal  space,  and  sand-bags  laterally.  Under  the  influence  of  an 
opiate,  or  in  extreme  cases  complete  etherization,  digital  or  mechanical 
pressure  should  be  employed  upon  that  portion  of  the  artery  lying  in 
Scarpa's  triangle  (Fig.  273).  Within  this  limit  the  point  of  compression 
may  be  shifted,  in  order  to  prevent  too  great  local  irritation. 

In  obstinate  cases  compression  on  the  cardiac  side  may  be  re-enforced 
by  forced  flexion  of  the  leg  on  the  thigh,  or  by  direct  pressure  upon  the 
tumor.  The  instances  will  be  exceedingly  rare  where  a  patient  and  skill- 
ful employment  of  these  methods  of  compression  will  not  succeed  in 


228  A  TEXT-BOOK  ON   SURGERY. 

effecting  a  cure.  Consolidation  may  result  in  one  or  two  hours,  or  it  may 
require  several  hours  or  days.  Acujjressure  and  massage  are  not  to  be 
employed.  The  elastic  bandage  of  Esmarch  has  not  given  results  wliicli 
would  justify  its  further  use.  When  comijression,  either  on  the  cardiac 
side  or  directlj^  upon  the  anenrism,  fails,  the  deligation  of  the  femoral, 
in  the  extreme  lower  angle  of  Scarpa's  space,  is  demanded. 

Aneurism  beyond  the  Popliteal. — Aneurism  of  the  peroneal  or  tibial 
arteries,  or  their  branches,  is  rare.  In  diagnosis  and  treatment  this  lesion, 
when  situated  in  this  i)ortion  of  the  arterial  system,  requires  little  or  no 
special  consideration.  When  the  tumor  is  so  situated  that  the  vessel 
immediately  involved  can  not  be  occluded  by  compression,  this  nuiy  be 
directed  to  the  femoral,  or,  in  aneurisms  of  small  size,  direct  pressure 
may  be  sufficient  to  effect  a  cure.  The  ligature  will  be  demanded  if  other 
methods  fail. 

Arterio-venous  Aneurism. — Arterio-venous  aneurisms  aio  of  two 
kinds.  In  one  variety  the  communication  is  direct,  the  contiguous  walls 
of  the  artery  and  vein  being  closely  adherent  immediately  around  the 
opening  leading  from  one  vessel  to  the  other.  This  is  called  direct  arterio- 
venous aneurism,  or  aneurisma.l  rarix. 

When  a  sac  intervenes  it  is  called  an  indirect  arterio-venous  or  vari- 
cose aneurism  (Fig.  271). 

The  cause  is  usually  tj'aiiniatic,  resulting  most  frequently  from  punct- 
ured wounds,  although  any  intianimatory  process  which  induces  necrosis 
of  the  arterial  and  venous  walls  may  lead  to  this  form  of  aneurism.  In 
exceptional  instances  the  communication  has  either  not  been  established, 
or  at  least  has  escaped  observation  for  several  years  after  the  injury. 
This  lesion  may  occur  in  any  portion  of  the  economy.  In  former  years 
it  was  observed  most  frequently  in  front  of  the  elbow-joint,  where  it  was 
produced  by  the  accidental  puncture  of  the  brachial  in  the  operation  of 
venesecfton.  It  occurs  not  infrequently  in  the  neck,  as  a  result  of  wound 
of  the  carotid  artery  and  internal  jugular  vein. 

The  chief  points  in  the  differential  diagnosis  between  varicose  aneu- 
rism and  aneurismal  varix  are  the  presence  of  a  tumor  and  the  peculiar 
aneurismal  hriiit  and  tremor,  which  conditions  exist  in  the  former. 

In  both  varieties  of  this  disease  the  veins  become  greatly  distended 
and  tortuous,  and  pidsate  forcibly  with  each  C(mtraction  of  the  heart, 
while  the  pulsation  in  the  artery  beyond  the  lesion  is  perceptibly  dimin- 
ished. 

In  the  treatment  of  varicose  aneurism,  compression  of  the  artery  should 
be  employed  on  both  sides  of  the  tumor,  while  direct  pressure  should  be 
made  upon  the  sac,  between  the  two  vessels.  When,  from  the  location 
of  the  lesion,  this  method  is  not  feasible,  or  when,  after  a  faithful  trial, 
it  has  failed  to  produce  a  consolidation  of  the  aneurism,  the  ligature  will 
be  required.  Catgut  should  be  used,  one  thread  being  i)assed  around  the 
artery  just  above,  and  another  just  below  the  tumor.  When  so  situated 
that  the  vein  involved  in  the  lesion  is  not  necessary  to  the  integrity  of  the 
part,  as  in  the  forearm,  this  may  also  be  secured  on  the  distal  side  of  the 
foramen  of  communication. 


SPECIAL  ANEURISMS.  229 

Operative  interference  in  cases  of  aneurismal  varix  is  not  so  fre- 
quently indicated  as  in  varicose  aneurism,  owing  to  the  comparatively 
slow  progress  of  the  disease.  Experience  has  shown  that  deligation  of  the 
affected  artery  is  far  more  dangerous  in  this  condition  than  in  the  indirect 
variety.  Fatal  secondary  hsemoiThage  is  recorded  in  a  numlier  of  in- 
stances, wliile  in  others  gangrene  has  resulted  from  closure  of  the  artery. 
Compression  should  be  employed  as  in  the  ti'eatment  of  the  form  just 
considered.  When  the  lesion  is  situated  in  the  vessels  of  an  extremity 
much  comfort  may  be  secured  liy  the  employment  of  an  elastic  bandage 
or  stocking,  as  in  the  treatment  of  venous  vaiix.  As  a  last  resort,  ampu- 
tation may  be  practiced. 


CHAPTER  XL 


LIGATION   OF   ARTERIES. 


Operative  F>urgery  of  tlie  Arteries. — In  tyino;  an  artery,  all  of  tlip  de- 
tails of  the  antiseptic  method  given  heretofore  shoiikl  be  scrupnlously 
carried  out.     While  the  incision  should  be  along  the  line  of  the  artery, 


it  should  lean  as  far  from  the  accomi^anying  vein  as  possible.     In  ap- 
proaching the  vessel  after  the  skin  is  divided,  the  fascia  and  aU  inter- 


vening tissues  should  be  grasped  between  two  long,  delicate  dissecting 
forceps  (Figs.  277,  278),  untU  the  sheath  is  reached,  and  this  is  opened 


LIGATION   OF   ARTERIES.  231 

in  tlie  same  manner.  As  soon  as  tlie  wall  of  the  artery  is  exposed  the 
sharp-pointed  instruments  should  be  laid  aside.  A  dull-pointed  aneu- 
rism-needle (Fig.  (J3j,  or  a  flexible  silver  probe,  should  now  be  passed 
between  the  sheath  and  the  vessel,  and  carried  carefully  around  the 
artery,  keeping  the  point  close  to  the  wall  of  the  vessel.  When  a  nerve 
or  vein  is  in  close  relation,  the  instrument  should  be  introduced  on  the 
side  nearest  these,  thus  insuring  their  exclusion.  The  dull-pointed 
probe,  bent  to  the  proper  curve,  may  be  used  to  great  adviintage  in 
almost  all  operations  upon  the  arteiies.  After  the  point  is  carried 
around  the  vessel  and  brought  up  out  of  the  sheath,  the  ligature  may  be 
tied  over  the  slight  bulbous  expansion  of  this  instrument,  whicli,  when 
withdrawn,  leaves  the  ligature  around  the  vessel. 

In  tying  the  catgut  the  double  loop  (see  Fig.  112)  should  be  used  for 
the  first,  and  the  single  loop  for  the  second  knot.  The  force  employed 
should  be  sufficient  to  occlude  the  vessel,  yet  not  enough  to  infiict  unne- 
cessary violence  upon  its  walls.  The  ends  of  the  string  should  be  cut 
off  for  one  fourth  to  one  half  of  an  inch  from  the  knot,  and  the  wound 
closed  for  a  permanent  dressing. 

Ligation  of  tlie  Innominate  Artery — Anatomy. — The  arteria-innomi- 
nata  is  derived  from  the  transverse  segment  of  the  arch  of  the  aorta, 
immediately  in  front  of  the  trachea,  just  behind  the  middle  of  the  ster- 
num, at  a  level  varying  from  one  half  to  one  and  a  half  inches  below  the 
upper  margin  of  the  manubrium. 

From  this  origin  it  travels  obliquely  upward,  backward,  and  to  the 
right  (crossing  the  trachea  from  its  center),  and  bifurcates,  near  the  upper 
margin  of  the  clavicle,  between  the  sternal  and  clavicular  origins  of  the 
sterno-mastoideus  into  the  carotid  and  subclaman  arteries,  the  first  of 
these  coming  from  its  anterior  aspect,  the  last  a  direct  continuation  of 
the  arch  of  the  innominate.  The  innominata  in  rare  instances  originates 
to  the  left  of  the  trachea  ;  more  frequently  it  is  given  off  before  it  reaches 
the  windpipe.  As  a  rule,  it  is  longer  in  females  than  in  males.  In 
twenty-eight  cases  in  which  I  measured  the  distance  of  the  origin  of  the 
innominate  from  the  commencement  of  the  aorta,  the  average  was  three 
inches  and  a  half.  In  thirty-seven  measurements  made  to  determine  the 
length  of  the  innominate  artery,  the  average  was  one  inch  and  a  half,  the 
shortest  specimens  being  three  fourths  and  the  longest  two  inches. 

Operation. — Place  a  firm  cushion  crosswise  beneath  the  shoulder- 
blades,  so  that  the  head  will  fall  well  back,  and  thus  draw  the  artery 
upward.  Have  an  assistant  draw  the  arm  and  shoulder  of  the  right  side 
forcibly  downward,  while  the  chin  is  elevated  and  the  face  turned  slightly 
to  the  left. 

AVith  the  patient  completely  anaesthetized,  and  every  arrangement 
made  for  expedition,  make,  from  the  center  of  the  interclavicular  notch, 
an  incision  about  three  inches  in  extent  along  the  clavicle.  A  second 
incision,  commencing  at  the  inner  border  of  the  sterno-mastoideus,  about 
two  inches  and  a  half  above  the  clavicle,  is  made  to  unite  with  the  first 
incision  at  the  middle  of  the  interclavicular  notch.  Dissect  the  flap  up- 
ward until  the  sterno-mastoid  muscle  is  exposed,  the  sternal  and  two 


232 


A  TEXT-BOOK   ON   SURGERY. 


thirds  of  the  clavicnlar  origins  of  which  should  be  divided  upon  a  grooved 
director  carefully  introduced.  Superficial  to  the  muscle  some  small  veins 
wiU.  be  found,  and  underneath  its  clavicular  portion  is  the  junction  of 


Fig.  2V9. — Showing  the  relations  of  the  part*  involved  in  delijation  of  the  innominate  artery  ;  the  right  sub- 
clavian and  carotid  in  their  first  divisions. 

the  subclavian  and  jugular  veins,  in  dangerous  proximity.  The  anterior 
jugular  veins  will  be  seen  immediately  beneath  the  muscle,  and  should 
be  tied  and  divided.  Dissecting  carefully,  with  the  handle  of  the  scalpel, 
the  connective  and  areolar  tissue  in  which  these  veins  are  imbedded,  the 


LIGATION  OF  ARTERIES.  233 

orio;ins  of  the  sterno-Tiyoid  and  ster no-thyroid  muscles  will  be  reached, 
and,  when  these  are  divided  carefully  upon  the  director,  the  right  carotid 
will  be  seen  near  the  center  of  the  wound.  Following  this  down,  the 
arteria  innominata  will  be  found  just  behind  i\\e  sterno-clavimlar  ariicw- 
lation  (Fig.  279).  Being  exposed  with  the  scalpel-handle,  or  any  dry  dis- 
sector not  likely  to  wound  the  vessel,  the  aneuilsm-needle  should  be  passed 
from  right  to  left  behind  the  artery,  care  being  taken  to  avoid  wounding 
the  right  vena  innominata  and  the  pneumogastric  nerve,  or  puncturing 
the  pleura,  in  which  the  artery  is  partly  imbedded.  It  is  well  to  bear  in 
mind  that  the  left  innominate  vein  crosses  this  artery,  although  usually 
very  low  down.  When  the  aorta  is  situated  low  in  the  thorax,  it  may  be 
necessary  to  remove  the  sternal  end  of  the  clavicle  and  a  segment  of  the 
sternum,  as  was  done  by  Cooper,  of  San  Francisco,  in  two  instances. 

An  element  of  danger  in  this  operation  is  the  origin  of  an  abnonnal 
branch  from  the  innominate.  In  the  cases  of  Lizars  and  V.  Mott  this 
anomaly  existed,  and  death  was  caused  by  Jicemorrhaye  at  the  seat  of 
the  ligature.  In  thirty-four  consecutive  subjects  which  I  examined  as  to 
this  feature,  I  found  an  abnonnal  branch  to  be  derived  from  the  innomi- 
nate in  five.  "When  the  necessity  for  occlusion  of  the  arteria  innominata 
ai'ises,  and  the  conditions  are  such  as  to  permit  it,  the  following  method 
should  be  followed :  The  right  common  carotid  should  first  be  tied,  one 
inch  above  its  origin.  By  a  careful  dissection  the  first  division  of  the 
subclavian  and  its  branches  should  then  be  exposed,  di-awing  the  internal 
jugular  to  the  outer  side  until  the  vertebral  is  secured.  Avoiding  the 
phrenic  nerve,  as  it  descends  to  the  inner  side  of  the  scalenus  anticus,  the 
mternal  mammary  and  branches  of  the  thyroid  axis  should  be  secured, 
and  finally  a  ligature  of  large,  smooth  catgut,  or  prepared  nerve  placed 
around  the  subclavian  artery,  about  the  middle  of  its  first  portion.  A 
careful  study  of  the  anatomy  and  surgery  of  this  region  leads  me  to  con- 
clude that  this  procedure,  though  difficult  of  execution,  offers  a  better 
prospect  of  success  than  deligation  of  the  larger  and  primitive  trunk, 
nearer  the  heart. 

In  the  operation  and  after-treatment  of  the  wound  the  most  careful 
antisepsis  should  be  practiced,  and  perfect  drainage  maintained. 

Ligation  of  the  Common  Carotid  Arteries  and  the  Internal  Jugular 
Vein— Anatomy . — In  one  hundred  and  twenty  dissections  I  found  the 
common  carotid  artery  to  liifurcate  on  a  U*vel  with  the  notch  between  the 
two  aliB  of  the  thyroid  cartilage  in  one  hundi'ed  and  sixteen.  The  anoma- 
lies of  this  vessel  are  so  rare  that  they  do  not  deserve  mention  in  this  work. 

Operation. — A  firm  cushion  should  be  placed  under  the  shoulders  and 
lower  part  of  the  neck,  with  the  chin  elevated,  and  the  face  turned  in 
the  du'ection  away  from  the  side  upon  which  the  operation  is  to  be  per- 
formed. A  line  extending  from  the  tragus  of  the  ear  to  the  sterno-cla- 
vicular  articulation  will  cover,  and  be  parallel  with,  the  internal  and 
common  carotid  arteries  in  their  surgical  length.  This  line  will  strike 
the  center  of  bifurcation  of  the  primitive  carotid  almost  invariably  on  a 
level  with  the  upper  border  of  the  thyroid  cartilage,  and  the  anterior  edge 
of  the  sterno-mastuideus  from  one  inch  and  a  quarter  to  one  and  a  half 


234 


A  TEXT-BOOK   ON   SURGERY. 


below  this  level.  The  point  of  election  is  al)out  one  inch  below  this 
bifurcation,  and  at  the  npper  border  of  the  anterior  belly  of  the  omo- 
hyoid niu.sele. 


ly 


-I 


J" 


Fio.  280.— Showing  lines  of  incision  and  relation  of  parts  involved  in  deligntion  of  the  common  carotid, 
above  and  below  the  anterior  belly  of  the  omo-hyoid,  and  the  external  carotid  below  the  lingual  and 


above  the  facial. 


The  incision,  being  made  with  its  direction  as  above  given,  its  center 
about  one  inch  below  the  bifurcation,  extending  from  one-and-a-half  to 
two  inches  above  and  below  this  point,  will  divide  first  the  integument. 


LIGATION   OF  ARTERIES.  235 

and  with  this  the  thin  platysma  myoides,  some  filaments  of  the  super- 
ficialis  colli  nerve,  of  no  importance,  and  some  small  veins  passing  from 
the  anterior,  either  to  the  internal  or  external  jugular  veins.  About 
the  center  of  the  wound  the  edge  of  the  mastoideus  will  be  seen,  and 
below  this  (usually)  the  anterior  belly  of  the  omo-Tiyoideus  (Fig.  280, 
lower  half).  The  sheath  of  the  carotid  and  jugular  vein  is  now  exposed, 
often  crossed  by  the  thyroid  veins,  and  the  cervicalis  descendcns  artery, 
the  descendcns  noni  nerve  almost  invariably  lying  upon  the  center  of  the 
sheath,  being  i^arallel  with  the  axis  of  the  common  and  internal  carotids. 
In  two  instances  I  have  seen  the  superior  thyroid  artery  turn  du-ectly 
down,  in  front  of  the  common  trunk,  for  an  inch  or  more,  and  then  turn 
abrui)tly  inward  to  be  distributed  to  the  thyroid  body.  Under  such  ab- 
normal conditions  this  vessel  would  probably  be  divided.  The  communi- 
cans  noni  is  occasionally  found  crossing  the  sheath  from  without  inward, 
to  anastomose  with  the  descendens.  These  nerves  will  be  drawn  to  the 
outer  or  inner  side  of  the  wound,  as  is  most  convenient.  The  sheath 
should  be  opened  on  its  tracheal  side,  as  far  as  possible  from  the  jugu- 
lar vein,  and  the  needle  passed  from  without  inward,  being  kept  close  to 
the  artery  in  order  to  avoid  wounding  the  rein  or  including  the  pneumo- 
gastric  or  sympathetic  nerves.  The  sheath  should  be  well  oi:)ened,  and 
the  artery  clearly  exposed,  so  that  the  needle  may  be  manipulated  with 
more  of  certainty  and  less  danger  from  these  too  common  and  unfortu- 
nate accidents.  In  several  instances  the  artery  has  been  transfixed  ;  the 
jugular  has  been  wounded  ;  the  pneumogastric  or  sympathetic  nerves 
included  in  the  ligature,  for  want  of  precision  in  separating  the  artery 
from  the  vein.  Certainly  the  danger  of  slough  in  the  artery  is  not  so 
great  as  the  dangers  above  enumerated.  Just  as  the  needle  is  being  in- 
troduced, pressure  above  upon  the  vein  would  empty  it  of  blood,  and  of 
course  diminish  the  danger  of  wounding  it. 

The  operation  of  tying  the  carotid,  just  below  or  behind  the  omohyoid, 
is  practically  the  same  as  that  just  described  (Fig.  280). 

In  order  to  secure  this  vessel  at  the  root  of  the  neck,  an  incision  shoidd 
be  made  in  the  carotid  line,  extending  from  the  sterno-clavicular  articu- 
lation upward  a  distance  of  three  or  four  inches,  and  between  the  two 
heads  of  origin  of  the  sterno-mastoid  muscle.  This  wUl  divide  the  integu- 
ment, superficial  fascia,  platysma,  and  deep  fascia,  and  some  descending 
superficial  nerves.  The  fibers  of  the  sterno-mastoid  may  be  sei)arated 
and  held  to  either  side  by  retractors.  Immediately  beneath  it  will  be 
found  the  anterior  jugular  vein,  and  some  small  branches  emi)tying  into 
it.  If  not  easily  displaced,  they  should  be  secured  with  a  double  liga- 
ture, and  divided  between  the  threads.  The  fibers  of  the  sterno-hyoid  or 
sterno-thyroid  muscles  should  next  be  divided  on  a  grooved  director, 
and  turned  aside  or  separated  in  the  line  of  the  artery.  The  vessel  will 
be  seen  deeply  situated  in  the  line  already  given.  The  ligature  should 
be  passed  from  the  outer  side.  Or  an  L-shaped  incision,  similar  to  that 
made  for  deligation  of  the  innominate  (Fig.  279),  may  be  made,  and 
the  carotid  found  by  separating  the  sternal  tendon  of  the  mastoideus 
muscle  and  turning  this  outward.      F©r  the  left  carotid  see  Fig.  281. 


236 


A  TEXT-BOOK  ON  SURGERY, 


The  approach  to  the  vessel  in  this  region  should  be  very  cautious,  espe- 
cially ui)on  the  left  side  of  the  neck,  since  the  internal  jugular  vein 
crosses  from  the  outer  to  the  inner  side  by  the  front.     On  the  right  side 


4 


I'm 


m 


Fig.  281. — Showincr  the  relations  of  parts  involved  in  deli'jation  of  the  left  carotid,  at  the  root  of  the  neck, 
and  the  letl  subclavian  in  its  tirst  surgiciil  division. 

the  vein  is  a  little  more  external.  The  pneumogastric  nerve  lies  behind 
and  to  the  outer  side  of  the  artery,  while  the  inferior  thyroid  artery  and 
sympathetic  nerve  are  more  deeply  situated.      The  aneurism  -  needle 


LIGATION   OF  ARTERIES. 


23^ 


Flo.  282.— Showing  the  relations  of  the  important  organs  at  the  root  of  the  neck  and  apex  of  the  thorax. 
Frozen  horizontal  section  at  the  level  of  the  third  dora;il  vertebra.  (After  Braune.)  1.  Innominate. 
2,  Left  carotid.  3,  Left  subclavian.  4,  Right  subclavian  arteries.  5,  6,  Left  and  rii;lit  innominate 
veins,  7  and  8,  Subclavian  veins.  9,  Inferior  thyroid  vein.  10,  Trachea.  11,  (Esophagus.  12, 
Spinous  process  of  second  dorsal  vertebra,    a  a,  Pneumogastric  nerves.    6,  Phrenic  nerves. 


238 


A  TEXT-BOOK   ON   SURGERY. 


should  be  passed  around  the  artery,  from  the  outer  toward  the  innei 
side. 

In  the  "Prize  Essay"  of  the  American  Medical  Associnticm  for  1878  I 
collected  histories  of  789  cases  in  which  the  common  can  it  id  artery  had 
been  tied  for  all  causes,  of  which  323,  or  41  per  cent,  died.  An  analysis 
of  these  cases  is  impossilde  hei'c.  I  do  not  believe  tiiat  the  death-rate 
will  ever  again  reach  this  alarming  iigure.  The  introduction  of  animal 
ligatures  and  antisepsis  have  already  greatly  diminished  the  death-rate 
in  operations  upon  the  arteries. 


Fio.  283. — Horizontnl  section  at  the  level  of  the  seventh  cervical  vertebra.  1,  1,  Tlie  right  and  Ictl  com- 
mon carotiil  urtcrie*  and  the  internal  .ju.'ular  veins.  2,  The  rii.'lit  and  left  vertebral  arteries  and  veins. 
Directly  between  the  vertebral  and  carotid  arteries  is  seen  the  svmpatbetie  nerve  and  the  interior 
thyroid  artery  and  sotne  of  itii  branches.  Tlic  pneumoijastric  nerves  are  seen  between  and  sliiihtly 
posterior  to  the  internal  jugular  veins  and  the  common  carotids.  3,  Trachea.  4,  (Esophajriis.  .'j, 
Transversalis  colli  artery  and  veins  and  descending  branches  of  the  subclavian  ailery.  6,  Cords  of 
brachial  plexus.     7,  7,  External  jugular  vein,     (.\fter  Braune.) 

Thirty-four  cases  are  on  record  in  which  both  trunks  were  tied,  of 
which  twenty-five  recovered.* 

Ligation  of  fhe  Internal  Carotid  Artery — Anatomy. — This  vessel  is 
a  direct  continuation  of  the  common  trunk,  and,  while  straight  in  its 
lower  portion,  it  becomes  slightly  tortuous  as  it  approaches  the  carotid 
canal.  An  abnormal  branch  was  found  to  be  derived  from  its  first  portion 
in  seven  of  one  hundred  and  twenty  dis.sections. 

Operation. — The  positicm  is  the  same  as  for  tying  the  common  trunk. 

*  Op.  cit.     See  also  Riegner's  case,  "Centrulblatt  fiir  Chirurgie,"  No.  26,  1884. 


LIGATION   OF   ARTERIES. 


239 


The  incision  should  be  made  in  the  carotid  line,  with  its  center  from  one 
half  to  three  quarters  of  an  inch  above  the  upper  border  of  the  thyroid 
cartilage.  The  same  structures  will  be  divided  supei-tioially,  and  the 
veins  will  be  seen  superficial  to  the  artery.    As  shown  in  C7,  Fig.  285,  they 


Fio.  284.— The  usual  relation  of  the  contents  of  the  surgical  triangles  of  the  neck.      From  the  author's 

dissections. 


may  cross  the  internal  carotid  almost  at  a  right  angle,  or  (as  in  A  or  B) 
they  may  empty  into  a  single  trunk,  and  run  parallel  with  the  external 
carotid.  This  last  is  the  most  usual  way.  but  it  will  be  scarcely  possible 
to  ligate  the  internal  carotid  without  ligature  and  division  of  some  of 


240 


A  TEXT-BOOK   ON   SURGERY. 


these  veins.  The  descend ens-noni  nerve  will  be  seen  running  along  the 
artery,  the  liypocjlossal  crossing  it  about  one  inch  from  tlie  bifurca- 
tion.    The  vessel  being  ex])osed,  the  needle  is  introduced  on  the  out- 


Fig.  285. — Relation  of  tho  veins  to  the  carotids.     (Life  size.) 

er  side,  avoiding  the  jugular  vein  and  pneumogastric  nerve  exter- 
nally, the  external  carotid  internally,  and  the  hypoglossal  nerve  su- 
perficially. The  pharyngea  ascendens  is  in  intimate  relation  to  the 
internal  carotid,  running  parallel  with  it  on  its  inner  aspect.  Occa- 
sionally the  first  cervical  ganglion  of  the  sympathetic  extends  as  low- 
as  this  point.  It  will  be  avoided  by  keeping  the  needle  close  to  the 
artery. 

The  internal  carotid  artery  has  been  tied  nineteen  times,  w^ith  twelve 
recoveries.*  In  six  of  the  fatal  cases  the  common  trunk  had  been  pre- 
viously and  ineffectually  secured,  and  in  the  remaining  case  I  tied  the 
common,  external,  and  internal  carotids,  in  removing  an  immense  tumor 
which  involved  these  vessels.  The  patient  died  from  shock  in  eighteen 
hours. 

Ligation  of  ilie  External  Carotid  Artery . — From  the  extensive  dis- 
tribution of  its  branches  to  the  exposed  portions  of  the  neck  and  face, 
the  external  carotid  artery  demands  a  more  careful  consideration  than 
any  single  vessel  of  the  human  body. 

*  Op.  cit. 


LIGATION   OF  ARTERIES. 


241 


Anatomy. — Leaving  the  common  trunk  at  the  upper  border  of  the 
thyroid  cartilage,  well  forward  of  the  anterior  border  of  the  sterno- 
mastoid  muscle,  this  vessel  arches  forward  and  upward  (its  concavity 
looking  toward  the  lobule  of  the  ear)  until,  on  an  average  of  "92  inch 
above  the  bifurcation,  after  giving  off  the  facial  branch,  it  turns  ob- 
liquely upward  and  backward  to  a  point  opposite  the  insertion  of  the 
external  pterygoid  muscle  into  the  neck  of  the  condyle  of  the  lower 
jaw,  where  it  tenninates  by  dividing  into  the  temporal  and  internal 
maxillary  arteries. 

Eight  regular  branches  belong  to  this  vessel  (though  some  anatomists, 
among  whom  are  Hyrtl,  Wilson,  and  Richardson,  describe  nine).  On 
its  anterior  aspect  arise  from  below,  upward,  the  thyroidea  superior, 
lingual  is,  maxillaris  externa,  and  maxillaris  interna.  On  its  poste- 
rior and  internal  aspect  the  pharyngea  ascendens,  and  posteriorly  the 
occipitalis,  auricular  is,  and  temporalis. 


Anterior  temporal. 


Posterior  temporal. 


Auricular. 


Occipital.  — 


Stemo-mastoid. 
Pharyngeal. 


Transverse  facial. 

--  Internal  maxillary. 

--  Parotid  branches. 

—  Ascending  palatine. 
--  Tonsillar. 

'"  Facial. 
Lin^'ual. 

'--Hyoid  branches. 

Superior  thyroid. 
Descending  cervical. 


Fig.  286. — The  external  carotid  and  its  branches.     The  average  arrangement  of  one  hundred  and  twenty-one 

dissections  by  the  autiior.     (Life  size.) 

The  usual  arrangement  of  these  branches  is  seen  in  Fig.  286,  which 
is  the   average  of  one   hiindred   and   twenty-one   dissections.      Abnor- 
mal deviations  from  this  relation  of  the  branches  to  the  parent  trunk 
.16 


242 


A  TEXT-BOOK   ON  SURGERY. 


occur  occasionally,  and  types  of  these  may  be  seen  in  Figs.  287 
and  288.  The  relations  of  the  veins  to  these  arteries  are  shown  in 
Fig.  283. 

Operation. — The  external  carotid  may  be  tied  in  the  majority  of  cases 
at  two  points,  viz.,  between  the  origins  of  the  thyroidea  superior  and 
Ungiuilis,  about  one  quarter  of  an  incli  above  the  sei)tuni  of  bifurcation 
(see  Fig.  280),  or  between  the  origins  of  the  max/Uari.s  exlcnut  and  auri- 
cularis,  about  one  inch  and  a  half  above  the  thyroid  cartilage.  At  the 
lower  point  of  election  the  operation  is  the  same  as  for  ligature  of  tlie 
internal  carotid  on  the  same  plane,  except  that  the  external  carotid  is 
usually  from  one  quarter  to  one  half  inch  nearer  the  median  line  than  the 
internal. 

Notwithstanding  that  the  analysis  of  one  hundred  and  twenty-one 
consecutive  dissections  has  convinced  me  of  the  propriety  of  ligatuiing 


Fig.  287. ^Unusual  arraneement  of  the  branches  of  the  external  carotid.  1,  The  linjual  and  facial  from  a 
common  oriirin.  2,  "The  lingual  and  facial  superior  thjroid  from  a  common  ori^'in.  3,  Close  relation  of 
first  five  branches  to  each  otlier. 


this  vessel,  and  that  the  history  of  the  cases  in  w^hich  it  has  been  tied 
shows  a  rate  of  mortality  far  below  that  of  ligature  of  the  common  carotid, 
yet  the  proximity  of  large  and  important  branches  to  each  other,  or  to 
the  bifiircation  of  the  common  carotid  in  many  instances,  makes  it  of  the 
utmost  importance  that  the  surgeon  should  proceed  with  great  care  and 
discretion.     The  wound  should  be  thoroughly  cleansed,  and  the  vessel 


LIGATION   OF  ARTERIES. 


243 


examined  with  sci'upulous  care  above  and  below  the  ligature,  and  any 
collateral  branch  or  branches  within  less  than  one  quarter  of  an  inch 
should  be  also  secured. 

Should  the  artery  be  found  to  be  normal  (as  in  Fig.  286),  I  would 
place  the  ligature  nearer  the  lingualls  than  the  bifurcation,  and  tie  this 
vessel  separately.  If  (as  in  Fig.  287,  3)  a  rare  form  should  exist,  I 
would  ligature  close  to  these  branches,  and  tie  each  of  them  in  its  turn. 
This  same  conservative  rule  iiiust  apply  to  every  case. 

The  operation  at  or  above  the  posterior  belly  of  the  digastric  is  com- 
paratively safer,  and  is  applicable  to  all  lesions  above  this  point.  The 
incision  should  extend  from  the  lobule  of  the  ear  along  the  ramus  of  the 
jaw,  down  to  the  level  of  the  thyroid  cartilage.  Cutting  through  the 
superficial  structures,  the  artery  will  be  found  just  behind  the  posterior 
belly  of  the  digastric  muscle. 

Above  this  level — that  is,  after  the  artery 
enters  the  parotid  gland — it  is  so  situated  that 
it  should  not  be  cut  down  upon.  The  incision 
would  involve  tl^ie  facial  nerm,  causing  paral- 
ysis of  the  muscles  of  expression.  In  malig- 
nant disease  of  the  parotid,  where  this  gland 
is  removed,  the  vessel  may  as  well  be  secured 
here  as  not,  since  the  operation  itself  usually 
destroys  the  facial  nerve. 

It  is  a  remarkable  fact  that,  notwithstanding 
the  close  proximity  of  the  branches  of  the  ca- 
rotid, in  a  number  of  instances  in  which  it  has 
been  ligatured  without  the  precaution  of  secur- 
ing immediate  collateral  branches,  there  has  not 
followed  secondary  haemorrhage.  No  explana- 
tion of  this  fact  has  appeared  so  delinite  as  the 
one  given  by  Prof.  H.  B.  Sands,  "which  takes 
into  account  the  remarkable  reparative  power 
of  the  tissues  surrounding  this  vessel.  Sui:)pu- 
ration  is  extremely  rare,  the  wounded  tissues 
soon  become  consolidated  by  plastic  material, 
and  secondary  haemorrhage  is  prevented  by 
changes  occurring  outside  of,  as  much  as  by 
changes  taking  place  loithin,  the  vessel  liga- 
tured." 

On  account  of  the  importance  of  maintaining 
the  integrity  of  the  circulation  to  the  brain, 
ligation  of  the  common  carotid,  for  a  lesion  in 
the  distribution  of  the  external  carotid,  should 
never  be  perfonned  when  a  sufficient  distance 

remains  between  the  lesion  and  the  bifurcation  of  the  common  trunk  to 
allow  of  the  ajiplication  of  the  ligature.  I  have  the  histories  of  ninety- 
three  cases  of  ligature  of  the  external  carotid,  in  sixty-nine  of  which  this 
vessel  alone  was  tied.     Of  these  sixty-nine  cases  only  three  died,  while 


Fio.  288. — An  enlarsjed  superior 
thyroid  artery. 


244  A  TEXT-BOOK  ON  SURGERY. 

the  death-rate  after  ligature  of  the  common  trunk,  for  the  same  period, 
was  41  per  cent. 

Ligation  of  tlie  Superior  Thyroid  Arterij — Anatomy. — Tliis  branch 
was  present  in  every  instance  in  one  hundred  and  twenty-one  dissec- 
tions. It  originated  almost  invariably  on  a  level  with  the  thyroid 
notch.  In  one  of  twenty-five  cases  it  wiU  be  found  to  have  a  com- 
mon origin  with  the  lingual,  or  the  lingual  and  facial.  See  Fig. 
287,  1,  2. 

Operation. — With  the  neck  in  the  surgical  position,  i.  e.,  with  the 
head  thrown  back  and  the  face  turned  to  the  opposite  side,  make  an  in- 
cision two  inches  long,  parallel  with,  and  one  fourth  of  an  inch  in  front 
of,  the  carotid  line.  The  center  of  this  incision  must  be  on  a  level  vdth 
the  thyroid  notch.  Immediately  beneath  the  skin  and  platysma  myoidea 
will  be  seen  the  thyroid.,  lingual,  hyoid,  and  other  veins,  which  may 
assume  either  of  the  forms  or  relations  shown  in  Fig.  285,  A,  B,  being 
most  conmion.  These  being  tied  and  divided,  the  artery  will  be  found 
opposite  the  point  above  indicated. 

The  thyro-hyoid  nerve  wiU  occasionally  be  seen  passing  across  this 
artery,  although  usually  nearer  the  median  line.  The  external  laryngeal 
passes  beneath  it. 

Ligation  of  the  Lingual  Artery — Anatomy. — From  its  origin,  usu- 
ally opposite  the  cornu  of  the  hyoid  b(me,  it  ascends  obliquely  upward 
and  inward,  and  is  superficial  until  it  passes  underneath  the  xtyJo- 
hyoideus  and  digastricus  (posterior  belly),  and  then  more  deeply  behind 
the  hyo-glos.ms. 

In  two  of  one  hundred  and  twenty-one  cases  it  originated  in  common 
with  the  superior  thyroid,  and  in  two  other  instances  with  this  vessel  and 
the  facial.  In  thirty-one  of  one  hundred  and  twenty-one  cases  it  arose 
from  a  trunk  common  to  it  and  the  facial,  being  abnormally  associated  in 
one  in  every  three  and  a  half  dissections. 

Operation. — The  lingual  artery  may  be  secured  either  below  the 
digastric  or  above  this  point,  where  it  passes  beneath  the  hyo-glossus. 

For  the  low  operation  make  an  incision  as  in  the  case  of  the  superior 
thyroid,  except  that  its  center  should  be  opposite  the  os  hyoides.  The 
artery  Avill  be  found  in  the  lingual  triangle,  bounded  posteriorly  by  the 
external  carotid,  above  by  the  digastric  muscle,  below  by  the  os  hyoides. 
The  middle  constrictor  muscle  is  behind  it ;  the  platysma  myoides  in 
front,  and  under  this  the  veins  above  noted.  The  hypoglossal  nerve  is 
usually  just  ahore  it  as  it  ci'osses  the  carotid,  while  the  thyro-hyoid 
branch  of  this  nerve  crosses  the  artery  on  its  way  to  the  muscle  it 
supplies. 

The  high  operation  is  one  of  considerable  difficulty.  The  face  should 
be  well  turned  to  the  opposite  side,  the  chin  elevated,  and  held  per- 
fectly immovable.  Beginning  immediately  over  the  os  hyoides,  near  the 
median  line  of  the  neck,  an  incision  is  made  outward,  and  parallel  with 
this  bone  as  far  as  the  great  comu,  where  it  is  curved  upward  to  the 
angle  of  the  jaw  (Fig.  289).  Tliis  crescentic  Hap  is  turned  up,  and  with 
it  the  sub-maxillary  gland,  in  a  gi'oove  on  the  under  surface  of  which 


LIGATION   OF  ARTERIES. 


245 


the  facial  artery  runs.     As  soon  as  the  hyoid  bone  is  exposed  it  should 
be  fixed  with  a  tenaculum  and  drawn  steadily  down.      The  posterior 


# 


.^^ 


Fig.  289.— Ligation  of  the  right  subclavian  in  its  third  surgical  division ;  the  facial  in  the  neck  and  the 

lingual  beneath  the  hyo-glossus  muscle. 


belly  of  the  digastric  will  now  l)e  seen  passing  obliquely  downward 
and  forward  to  the  central  tendon  in  the  hyoid  bone.  Passing  beneath 
this  muscle,   and  superficial  to  the  hyo-glossus,  is  seen  the  hypoglos- 


246  A  TEXT-BOOK  ON  SURGERY. 

sal  nerve,  wliich  runs  ])arallel  with  and  above  the  artery,  depress  the 
posterior  belly  of  the  digastric,  insert  a  director  beneath  the  posterior 
fibers  of  the  hyo-glossus,  and  divide  these.  The  artery  will  be  found 
just  beneath  this  muscle,  resting  upon  the  middle  constricitor  of  the 
I)harynx. 

The  ligation  of  this  artery  is  frequently  practiced  ])reliminary  to  ex- 
cision of  the  tongue  for  malignant  disease,  and  occasionally  to  arrest 
hajmorrhage. 

Ligation  of  the  Facial  Artery — Anatomy. — The  facial  artery  was 
present  in  one  hundred  and  twenty  of  one  hundred  and  twenty-one  dis- 
sections. In  the  instance  in  wliich  it  was  missing  its  facial  distri'.nition 
was  taken  by  the  transverse  facial  from  the  temporal,  and  its  cervical 
by  branches  from  the  linyital  and  the  external  carotid.  Its  origin  is 
usually  about  one  fourth  of  an  inch  above  the  lingual.  It  is  the  long- 
est branch  of  the  external  carotid.  In  thirty-one  of  one  hundied  and 
twenty  cases  it  arose  in  common  with  the  lingual,  and  in  two  in- 
stances it  was  from  a  trunk  in  conuncm  with  this  artery  and  the  su^^e- 
rior  thyroid. 

Operation. — In  its  cervical  distribution  this  vessel  will  require  to  be 
tied  at  or  near  its  origin  from  the  carotid.  The  incision  alpng  the  axis 
of  the  carotid,  as  given  before,  with  its  center  a  quarter  of  an  inch  above 
the  hyoid  bone,  will  lead  to  the  facial.  The  posterior  belly  of  the  digas- 
tricHS  wiU  be  found  with  its  center  usually  above  the  origin,  but  soon 
crossing  the  artery.  The  ninth  nerve  is  just  below.  For  lesion  of  this 
vessel  in  the  face  it  can  be  readily  secured  as  it  crosses  the  inferior 
maxilla  in  the  depression  at  the  anterior  border  of  the  masseter  (Fig. 
290).  Before  making  the  incision,  which  should  be  parallel  with  the 
horizontal  portion  of  the  inferior  maxilla,  the  skin  should  be  well 
pulled  up  from  the  neck,  so  that,  after  healing,  the  cicatrix  will  fall  be- 
low the  jaw. 

Ligation  of  the  Ascending  Pharyngeal — Anatomy. — This  artery 
was  derived  from  the  external  carotid  in  one  hundred  and  eleven 
of  one  hundred  and  twenty-one  cases,  and  from  the  infernal  ca- 
rotid in  four  others.  It  usually  comes  off  at  a  point  opposite  the 
origin  of  the  lingual,  and  occasionally  from  the  bifurcation  of  the 
primitive  carotid.  A  pharyngeal  branch  is  not  uncommon  from  the 
occipital. 

Operation. — The  external  carotid  must  be  exposed  by  an  incision  the 
center  of  which  is  opposite  the  level  of  the  hyoid  bone.  The  vessel  wUl 
be  seen  ascending  between,  and  parallel  with,  the  external  and  internal 
carotids. 

One  fatal  case  is  recorded  from  haemorrhage  after  a  wound  of  the 
ascending  pharyngeal. 

Ligation,  of  the  Occipital  Artery — Anatomy. — The  occipital  was 
present  in  one  hundred  and  twenty  of  one  hundred  and  twenty-one  dis- 
sections, and  it  was  found  to  be  opposite  the  facial  in  the  majority  of 
cases.  In  the  subject  in  which  it  was  missing,  a  large  branch  from  the 
inferior  thyroid  (not  the  ascending  cervical)  took  its  distribution.     Not 


LIGATION   OF   ARTERIES. 


247 


infrequently  the  posterior  auricular  or  a  pharyngeal  branch  arose  from 
this  vessel. 

Operation. — It  may  be  secured  near  its  origin,  or  behind  the  mastoid 
process.  For  the  low  operation,  make  an  incision  in  the  carotid  line,  the 
center  of  which  is  about  one  inch  above  the  thyroid  notch.     After  divid- 


Fio.  2a0. — Ligation  of  the  posterior  tcmporul  at  iLe  zygoma,  and  ol'  tlie  I'ucial  upon  the  interior  maxilla. 

ing  the  deep  fascia  the  hypoglossal  nerve  will  be  seen,  which,  if  followed 
backward,  will  lead  unerringly  to  the  artery,  underneath  which  it  winds. 
The  posterior  belly  of  the  digastric  muscle  will  usually  require  to  be 
lifted  upward. 

Behind  the  mastoid  the  occipital  may  be  tied  where  it  passes  beneath 


248 


A  TEXT-BOOK  OX  SURGERY. 


tiie  cranial  attachment  of  the  sterno-mastoid  miisch'  (Fig.  291).  From 
one  half  to  three  fourths  of  an  inch  behind  the  mastoid  process  an  in- 
cision about  two  inches  long  should  be  made,  extending  upward  and 
backward.  The  aponeurosis  of  the  sterno-mastoid  muscle  is  divided  on 
a  directoi',  and  the  artery  exposed.     The  constant  relation  of  this  vessel 


Fio.  291. — Ligation  of  the  occipital  behind  the  mastoid  process  and  the  common  temporal  near  the  zygoma, 
also  showing  the  relations  of  the  facial  nerve  to  the  terminal  portion  of  the  external  carotid. 


to  the  gi'oove  on  the  under  surface  of  the  mastoid  process  will  serve  as  a 
valuable  guide. 

The  common  carotid  has  been  tied  in  several  instances  for  lesions  of 
the  occipital.     This  should  never  be  done. 

Ligation  of  the  Posterior  Anric^dar — Anatomy. — In  eleven  of  one 
hundred  and  twenty-one  dissections  this  vessel  arose  from  the  occipital, 
and  in  four  it  was  absent.  Its  origin  is  usually  one  inch  and  four  lifths 
above  the  thyroid  notch. 


LIGATION  OF  ARTERIES.  249 

For  anatomical  reasons,  in  lesions  of  this  artery  tlie  external  ca- 
rotid should  be  tied,  just  above  the  posterior  belly  of  the  digastric, 
between  its  origin  and  that  of  the  occipital .  It  runs  under  the  pa- 
rotid gland,  is  crossed  by  the  facial  nerve,  and  has  beneath  it  the  spinal 
accessory. 

Ligation  of  the  Temporal  and  Internal  3faxillary  Arteries — Anat- 
omy.— The  temporal  and  internal  maxillary  arteries  begin  at  the  termi- 
nal bifurcation  of  the  external  carotid,  in  the  substance  of  the  parotid 
gland,  at  an  average  distance  of  two  inches  and  nine  tenths  from  the 
thyroid  notch. 

Operation. — The  temporal  artery  may  be  secured  by  a  perpendicu- 
lar incision  immediately  in  front  of  the  tragus  of  the  ear,  where  it  crosses 
the  zygoma  superficially  (Fig.  291).  For  lesions  of  this  vessel  above  the 
temporal  fossa,  and  often  in  wounds  in  this  region,  the  ligature  will 
be  unnecessary,  since  direct  compression,  by  means  of  the  knotted 
bandage,  will  suffice.  AVhen  either  this  artery  or  the  internal  maodl- 
lary  are  wounded  in  the  substance  of  the  parotid  gland,  the  external  ca- 
rotid should  be  tied  at  the  posterior  belly  of  the  digastric.  The  same 
procedure  is  indicated  in  lesions  of  the  internal  maxillary,  in  its  deej)- 
er  portions. 

Ligation  of  the  Internal  Jugular  Vein. — The  intimate  relation  of  this 
vein  to  the  internal  and  common  carotid  arteries  renders  it  accessible  by 
the  same  incisions  laid  down  for  the  ligation  of  the  arteries.  The  vein 
is  contiguous  to  the  artery,  and  is  external  and  slightly  superficial  to  it. 
On  the  left  side,  at  the  root  of  the  neck,  the  Jugular  comes  more  to  the 
front,  while  on  the  right  side  it  tends  to  the  outer  side. 

The  rules  which  apply  to  the  ligation  of  arteries  apply  with  equal 
force  to  the  ligation  of  veins.  The  jugulars  should  be  encircled  vdth  a,n 
animal  ligature,  not  tied  with  a  lateral  loop,  as  has  been  practiced.  The 
aneurism-needle  should  be  passed  from  the  inner  side.* 

The  anterior,  external,  and  posterior  jugular,  and  other  veins  of  the 
neck,  do  not  demand  especial  consideration.  When,  in  operations  in  the 
neck,  it  becomes  necessary  to  divide  them,  a  double  catgut  should  be 
applied,  and  the  vessel  divided  between  the  two  ligatures. 

The  Subclavian  Arteries  and  their  Branches — Anatomy. — The  right 
subclavian,  lai'ger,  shorter,  and  more  superficial  at  its  origin  than  the 
left,  is  derived  from  the  innominate  behind  the  origin  of  the  carotid, 
about  the  level  of  the  upper  margin  of  the  clavicle  (more  frequently  above 
than  below  this  line),  behind  the  interval  between  the  two  tendons  of  the 
sterno-mastoideus.  It  is  the  direct  continuation  backward,  upward,  and 
outward  of  the  (trch  of  the  innominate,  and  is  continuous  with  the  axil- 
lary artery,  at  the  lower  edge  of  the  first  rib.  Its  average  length  is  2'83 
inches. 

The  left  snhclavian,  derived  l"2'i  inch  beyond,  to  the  left  of,  and  more 
deeply  situated  in  the  thorax  than,  the  innominate,  travels  almost  verti- 

*  See  Prof.  S.  TV.  Gross's  admirable  article  in  "  Ataerican  Journal  of  the  Medical  Sci- 
ences," 1867. 


250 


A  TEXT-BOOK   ON   SURGERY. 


cally  upward,  until  it  mounts  above  the  upper  surface  of  the  first  rib, 
when  it  curves  very  abruptly  outward  and  downward,  passing  behind  the 
scalenus  anticus  and  thence  to  the  lower  edge  of  the  first  rib.  Its  length, 
in  the  average,  is  3 '74  inches. 

Each  subclavian  has  three  surgical  divisions.     The  first  division  of 
the  right  artery  is  from  its  origin  from  the  innominate  to  the  inner  bor 


Cerviealis 
ascouduna. 

Thyroiden  1 
inferior,  f 

Transversa-  )  _ .^        ■     M  Werfebnalis 

lis  colli,  f 

Scapuliiria 

[losterior.  f  jg^^   ^^ig^  _jxs  ,mK, 

"      ""     ILr*, 

Suprascapu-  i  ■^^-»^»^  «.m  -^bk,.  ^ 

lario.  f 

Intcroostalis  ( 

superior,  f 

Mammaria  I 

interna.  | 


Arteriae  Coronariae 


Flo.  292.— Relation  of  the  {jreat  vessels  to  each  other  at  their  origins  from  the  arch  of  tlie  aorta,  and  the  rela- 
tion of  Ujc  branches  of  the  subclavian  arteries  to  each  other,     i'rom  the  author's  dissections. 


der  of  the  scalenus  anticus.  That  of  the  left  artery,  from  its  origin  at 
the  arch  of  the  aorta  to  the  inner  border  of  the  left  scalenus  anticus 
(Fig.  292). 

The  second  and  third  portions  of  bf)th  vessels  are  identical  as  re- 
gards direction  and  relation,  being  different  in  the  origins  of  their 
respective  branches.  The  second  surgical  division  of  each  is  entire- 
ly to  the  inner  side  of  the  inner  border  of  the  first  rib.  The  tJdrd 
portion  rests  chiefly  on  the  upper  surface  of  the  first  rib,  and  extends 
from  the  outer  border  of  the  scalenus  anticus  to  the  lower  border  of 
this  rib. 

The  first  portion  of  the  rigJd  subclavian  varies  from  three  fourths  to 
one  inch  and  a  half  in  length,  the  average  length  being  1'15  inch. 

The  first  portion  of  the  left  ai-tery  varies  from  one  inch  and  a  half  to 
three  inches,  the  average  length  being  2 "06  inches. 


LIGATION  OF   ARTERIES. 


251 


Transverse  Cervtcaf 


The  second  portion  of  the  rigM  subclavian  averaged  '58  inch,  the 
same  division  of  the  left  subclavian  being  -56  inch  in  length. 

The  third  portion  of  the  right  artery  is  a  little  less  ;  the  same  division 
of  the  left  subclavian  a  little  more  than  I'll  inch  in  length. 

Nine  important  branches  arise  directly  or  indirectly  from  tlie  subcla- 
vian arteries :  the  vertebral,  internal  mammary,  transversalis  colli, 
suprascapular,  inferior  thyroid,  cervicalis  ascendens,  superior  inter- 
costal, profunda  cervicis,  and  posterior  scapular. 

The  rigid  vertebral,  the  branch  most  constant  in  origin,  arises  from 
the  superior  and  posterior  aspect  of  the  main  trunk  (Fig.  293)  and  passes 
upward  to  the  verte- 
bral foramen,   in  the  AscendingCervical  \ 

sixth  cervical  verte- 
bra ;  at  times  to  the 
■fifth  ;  less  frequently 
to  the  fourth.  The 
relation  of  this  branch 
is  important.  In  the 
vast  majority  of  sub- 
jects it  will  be  found 
between  one  fourth 
and  three  ft)urths  of 
an  inch  to  the  inner 
side  of  the  inner  mar- 
gin of  the  scalenus 
anticus. 

The  left  vertebral 
(Fig.    292)   arises,   in     ^  t,,      ^  ,     •  ,      ^  ,    •  ^  ■    ,       ,       r. 

^      °  '  Fig.  293.— Plan  of  the  ritrht  subclavian  artcvv  and  its  branches.    From 

4    per    cent    of    cases,  the  author's  dissections.     (.Alter  (Juaiu.) 

from   the   aorta.     In 

most  subjects  it  will  be  found  within  three  fourths  of  an  inch  of  the  left 

scalenus  muscle. 

The  internal  m  am  ma  rg  artery  arises  at  the  inner  border  of  the  sca- 
lenus anticus.  It  is  occasionally  from  the  thyroid  axis.  The  phrenic 
nerve  passes  usually  in  front,  occa,siona]ly  behind  it.  Beliind  the  costal 
cartilages  it  runs  parallel  with  the  edge  of  the  sternum,  about  half  an 
inch  external  to  it. 

The  thyroid  axis  arises  also  just  within  the  scalenus.  The  inferior 
thyroid  branch  arises  from  the  axis,  in  almost  every  case  on  the  left  side. 
On  the  right,  in  twenty-six  cases  examined,  it  originated  from  the  in- 
nominate  in  three,  and  directly  from  the  subclavian  in  three  instances. 
It  passes  upward  (inclining  at  first  a  little  inward)  until  it  arrives  at  a 
point  between  the  third  and  seventh  (incomplete)  rings  of  the  trachea, 
where  it  turns  abruiitly  inward,  going  behind  the  common  carotid  and 
jugular,  in  front  of  the  vertebral,  and  is  distributed  chiefly  to  the  lower 
portitm  of  the  thyroid  body. 

The  transversalis  colli  passes  outward  in  front  of  the  scalenus  muscle 
and  the  phrenic  nerve,  underneath  the  omo-7iyoid,  and  in  front  of  or 


252  A  TEXT-BOOK   ON  SURGERY. 

between  the  cords  of  the  brachial  plexus,  and  is  distributed  to  the  tra- 
pezius muscle,  sending  a  branch  in  the  direction  of  the  posterior  border 
of  the  scapula,  which  anastomoses  with  the  jmdcrior  .vapiilar  artery  ; 
and,  when  this  last  vessel  is  not  present,  this  des(!(mding  branch  is  con- 
tinued along  the  border  of  the  scapula  to  anastomose  with  the  subscapu- 
lar liranch  of  the  axillary. 

The  suprasrapular  artery,  intimately  associated  with  the  preceding, 
travels  suddenly  downward  and  outward  from  its  origin  near  the  inner 
edge  of  the  scalenus  antlcus,  passes  between  the  subclavian  artery 
and  vein,  in  front  of  the  phrenic  nerve,  crosses  in  front  of  the  third 
division  of  the  main  trunk,  and  goes  to  the  suprascapular  fossa  under 
the  protection  of  the  clavicle,  anastomosing  with  the  dorsaUs  scapulae. 
of  the  subscapidaris.  It  gives  off  a  branch  (frequently  wounded  in 
operations  in  this  vicinity)  which  pass(;s  behind  the  steriio-niastoideiis 
and  along  the  upper  border  of  the  manubrium.  (It  is  nut  usually  men- 
tioned.) 

The  right  siqM'rior  iidercostal  artery  comes  from  the  second  division 
of  the  subclavian  in  almost  every  instance  ;  occasionally  from  the  first. 
The  left  is  usually  from  the  fii-st  division. 

The  posterior  scapular,  one  of  the  most  important  branches  of  the 
subclavian,  in  a  surgical  view,  since  it  must  be  in  dangerous  proximity 
to  a  ligature  applied  in  the  third  surgical  division  (not  given  in  many 
standard  text-books,  except  as  an  occasional  branch  of  this  artery),  was 
present  in  thirty-six  of  fifty-two  dissections,  or  69  per  cent.  It  was 
jiresent  in  nineteen  of  twenty-six  on  the  rigJit  side,  and  in  seventeen  of 
twenty-six  on  the  left.  In  twenty-three  of  the  thirty-six  cases  in  which 
it  was  present  it  was  derived  from  the  third  division  ;  in  the  remaining 
thirteen,  from  the  second  division,  close  to  its  outer  limit.  On  the  right 
side  74  per  cent  came  from  the  subclavian,  within  one  fourth  of  an  inch 
to  the  outer  and  inner  side  of  the  external  border  of  the  scalenus  muscle  ; 
26  per  cent  external  to  this. 

On  the  left  side  82  per  cent  were  within  one  fourth  of  an  inch  to  the 
outer  and  inner  side  of  the  line  dividing  the  middle  and  external  thirds 
of  the  main  trunk  ;  18  per  cent  were  to  the  outer  side  of  this.  The  tend- 
,  ency  of  this  important  branch  is  to  originate  near  the  scalenus,  i.  e., 
within  one  fourth  of  an  inch  of  its  outer  edge.  When  this  vessel  is 
present  the  transversalis  colli  is  small,  and  when  absent  the  descending 
branch  of  the  transversalis  takes  its  distribution.  Passing  outward  be- 
hind the  most  superficial  cords  of  the  brachial  plexus,  it  tiirns  sliarjily 
downward,  along  the  posterior  border  of  the  scapula,  to  anastomose  with 
the  subscapular  branch  of  the  axillary. 

Operation — The  Right  Huhclaman  in  its  First  Surgical  Division. — 
The  incisions  are  the  same  as  for  the  arteria-innominata  (Fig.  279). 
When  the  sterno-hyoid  and  sterno-thyroid  muscles  have  been  divided 
on  the  director,  the  internal  jugular  vein  will  be  seen  directly  in  front 
of  the  artery.  It  may  be  drawn  to  the  inner  side  (or  outer,  if  more 
convenient),  carefully  using  for  this  purpose  a  dull  retractor.  Care 
must  be  exercised  not  to  injure   the  pleura  which    rises  against  the 


LIGATION   OF  ARTERIES.  253 

artery  in  deep  inspiration.  A  dull-pointed  aneurism-needle  may  now 
be  passed  around  the  vessel,  taking  care  not  to  wound  the  subclavian 
or  innominate  vein,  or  the  recun-ent  laryngeal  nerve.  The  vertebral, 
internal  mammary,  and  branches  of  the  thyroid  axis,  should  also  be 
secured. 

The  conditions  which  will  justify  this  operation  will  rarely  occui-,  yet, 
when  the  operation  is  demanded,  every  source  of  danger  from  haemor- 
rhage should  be  avoided.  The  necessity  of  securing  the  carotid  at  the 
same  operation  must  be  determined  by  the  ojjerator.  I  am  of  the  opinion 
that  it  is  safer  to  occlude  this  vessel  also. 

The  suhclaman  artery  has  been  tied  in  its  first  surgical  division  eight- 
een times,  and  all  fatal.  In  five  of  these  cases  the  common  carotid  was 
also  tied.  In  only  one  case  was  the  left  subclavian  tied.  Of  the  thirteen 
single  operations,  two  (Ay res  and  Bullen)  were  for  the  arrest  of  hgemor- 
rhage  from  shot  wounds  in  military  practice,  with  one  death  in  half  an 
hour  and  one  on  the  eighth  day,  from  hsemorrhage.  The  other  eleven 
cases  are  given  on  page  221.  In  only  five  of  these  thirteen  cases  is  the 
source  of  hemorrhage  stated,  and  in  each  of  these  the  bleeding  was  from 
the  distal  side  of  the  ligature,  the  proximal  side  being  closed.*  A 
knowledge  of  this  fact  leads  me  to  insist  upon  the  ligation  of  the  verte- 
])ral  and  other  branches  of  the  first  division. 

In  five  instances  the  right  carotid  was  also  tied  simultaneously  by 
Liston,  Parker,  Hobart,  Cruveilhier,  and  Kiihl.  In  three  of  these,  fatal 
haemorrhage  ensued  from  the  distal  side  of  the  ligature. 

The  left  suholavian  artery  was  tied  in  its  first  division  once  by 
Rodgers,  and  fatal  ha?morrhage  occurred  from  the  distal  end  of  the 
artery. 

Ligation  of  the  Left  Subclavian  Artery  in  its  First  Surgical  Divis- 
ion— Operation. — From  a  point  on  the  clavicle  one  fourth  the  distance 
from  the  center  of  the  interclavicular  notch  to  the  acromion  process  com- 
mence an  incision,  and  carry  it  to  the  inner  border  of  the  sternal  tendon 
of  the  mastoid  muscle.  From  the  inner  extremity  of  this  line  carry  a 
second  incision  for  three  inches  along  the  anterior  border  of  the  sterno- 
mastoideus.  In  dissecting  this  flap  lift  with  it  the  mastoid  muscle  divided 
upon  the  director,  then  divide  the  sterno-hyoid  and  thyroid  muscles,  and 
feel  for  the  pulsation  of  the  artery,  which  ascends  deeply  behind  and  a 
little  outside  the  sterDO-clavicular  articulation.  The  internal  jugular 
vein  will  be  drawn  outward,  and,  passing  the  finger  along  the  inner  bor- 
der of  the  scalenus  muscle,  the  artery  will  be  felt  to  pulsate  (Fig.  281). 
The  thoracic  duct  usually  is  to  the  right  of  and  a  little  behind  the  artery 
opposite  the  upper  border  of  the  sternum.  On  a  level  with  the  insertion 
of  the  scalenus  it  arches  to  the  left,  crosses  in  front  of  the  subclavian, 
in  front  of  the  scalenus,  behind  the  internal  jugular,  and  curves  down- 
ward to  empty  into  the  subclaiiian  at  its  junction  with  the  jugular  to 
form  the  left  innominate  vein.  On  account  of  the  intimate  relations  of 
the  thoracic  duct  to  the  left  subclavian  artery  as  this  vessel  goes  behind 

*  The  autlior's  "Essays,"  William  Wnod  &  Co.,  1878. 


254  A  TEXT-BOOK  ON"  SURGERY. 

the  scalenus,  the  ligature  should  not  be  attempted  close  to  this  muscle, 
nor  should  the  dissection  be  carried  fully  to  the  scalenus.  The  artery 
should  be  tied  as  low  down  as  possible,  the  duct  being  less  likely  to  be 
injured  here,  since  in  passing  behind  the  aorta  it  is  deeper  than  the 
artery.  It  will  be  found  behind  and  to  the  right,  the  pneuniogastric  in 
front  and  to  the  right,  the  left  vena  innominata  crossing  in  front,  while 
the  pleura  is  directly  behind. 

The  vertebral  and  other  branches  of  the  left  subclavian  are  in  such 
proximity  to  the  thoracic  duct  that  it  will  be  dangerous  to  attempt  to  tie 
them  at  this  point. 

Ligation  of  the  Subclavian  Arteries  in  their  Second  and  Third  Sur- 
gical Divisions — Operation. — The  procedure  is  essentially  the  same  on 
the  two  sides.  Place  the  shoulders  upon  a  cushion,  pull  downward  on 
the  arm  of  the  side  to  be  operated  upon,  and  turn  the  i)atient's  face  to  the 
opposite  side.  Find  the  location  of  the  scalenus  anticus,  as  in  the  pre- 
ceding operation.  Slide  the  skin  well  down  upon  the  clavicle,  and  along 
this  bone  make  an  incision  three  or  four  inches  in  length,  commencing 
one  inch  to  the  inner  side  of  the  scalenus  muscle  and  terminating  near 
the  anterior  edge  of  the  trapezius.  Allowing  the  skin  to  resume  its  nor- 
mal relations,  the  incision  will  be  carried  above  the  clavicle.  Upon  a 
director  divide  the  outermost  of  the  clavicular  fillers  of  the  mastoid 
muscle.  The  internal  jugular  vein,  seen  in  the  anterior  portion  of  the 
wound,  will  be  carefully  drawn  to  the  inner  side,  the  operator  keeping 
well  above  the  junction  of  this  with  the  subclavian,  and  thus  avoiding 
the  lymphatic  duct. 

A  x>i'<>niinent  plexus  or  group  of  veins,  viz.,  the  external  Jugular, 
transversalis  colli,  and  suprascapular,  will  be  seen  traversing  the 
wound,  coming  from  their  respective  oiigins,  tf)ward  the  subclavian, 
near  the  Jugular.  These  should  be  secured  with  a  double  ligature,  and 
divided,  or  held  aside.  Dissecting  carefully,  the  suprascapular  and 
transversalis  colli  arteries  will  be  observed  running,  in  general,  in  the 
dii'ection  of  the  first  incision.  The  posterior  belly  of  the  omo-hyoid  may 
be  found  in  the  upper  margin  of  the  wound,  crossing  the  scalenus  at 
about  a  right  angle.  The  transversalis  colli  and  the  suprascapular  may 
be  secured  or  held  to  one  side,  the  finger  passed  along  the  scalenus  until 
the  tubercle  on  the  first  rib  is  felt,  immediately  behind  which  the  artery 
will  be  found.  If  it  shall  have  been  detennined  to  tie  the  artery  in  its 
second  portion,  the  scalenus  anticus  muscle  will  be  cut  upon  a  direc- 
tor, the  operator  being  careful  to  avoid  the  phrenic  nerve,  which  cr.osses 
the  muscle  in  front,  coming  from  above  downward  and  inward,  (It  is 
between  the  layers  of  the  sheath  of  this  muscle.)  The  ligature  is  next 
passed  around  the  artery  from  before  backward,  care  being  taken  not  to 
wound  the  pleura. 

If  the  third  division  of  the  artery  is  to  be  secured,  the  part  of  the 
above  operation  relating  to  the  division  of  the  scalenus  will  be  omit- 
ted. The  nearest  cord  of  the  brachial  plexus  must  be  carefully  ex- 
cluded, posteriorly  to  the  artery  ;  the  subclavian  vein  in  front  and  be- 
low (Fig.  289). 


LIGATION   OF   ARTERIES.  255 

The  subclavian  arteries  have  been  tied  behind  the  scalenus  anticus 
thirteen  times,  with  four  recoveries.  All  of  the  fatal  cases  were  on  the 
right  side. 

In  one  of  the  "Prize  Essays"  of  the  American  Medical  Association  I 
j)ublished  the  histories  of  two  hundred  and  fifty-one  ligations  of  the  sub- 
clavian artery  in  its  third  surgical  division,  of  which  one  hundred  and 
thirty-four  ended  fatally.  As  far  as  these  histories  relate  to  aneurism 
they  have  been  given.  A  study  of  the  remaining  cases  led  me  to  con- 
clude that  in  all  lesions  causing  dangerous  haemorrhage  in  the  upper 
l>rachial  or  axillary  regions  an  effort  should  be  made  to  control  the  bleed- 
ing at  the  seat  of  injury.  Failing  in  this,  deligation  of  the  subclavian, 
in  its  third  division,  is  demanded. 

Ligation,  of  the  Vertebral  Artery — Operation. — Locate  by  pressure 
the  carotid  tubercle  (the  transverse  process  of  the  sixth  cervical  vertebra). 
The  point  at  which  the  artery  is  to  be  secured  is  one  inch  directly  below 
this  bony  prominence,  which  must  be  the  center  of  a  perjaendicular  in- 
cision, four  inches  in  length.  Commence  the  incision  at  the  outer  bor- 
der of  the  sterno-mastoid  muscle,  where  the  external  jugular  vein 
crosses.  The  internal  jugular  is  seen  and  drawn  inward.  The  transverse 
cervical  artery,  and  one  or  two  smaller  veins,  are  met  with  next,  and 
drawn  to  the  outer  side  of  the  wound.  The  scalenus  anticus  muscle  is 
now  brought  into  view,  and  to  the  inner  side  of  this  a  depression  be- 
tween this  muscle  and  the  lougus  colli.  In  this  sulcus  the  artery  lies, 
the  vein  being  in  front  of  it.  In  my  case  I  had  to  tie  the  vein  with 
a  double  ligature,  divide,  and  turn  the  ends  aside  in  order  to  secure  the 
artei'y. 

Ligation  of  the  Internal  Mammary — Operation. — This  vessel  may 
be  secured,  as  has  been  described,  close  to  the  parent  trunk,  or  ir  may 
be  tied  in  one  of  the  intercostal  spaces.  In  the  third  or  fourth  space 
make  an  incision,  about  two  inches  in  length,  obliquely  from  without 
inward  and  d(j\\Tiward,  the  center  of  which  should  be  about  half  an 
inch  external  to  the  edge  of  the  sternum.  Divide  the  fibers  of  the 
pectoralis  major  and  the  intercostal  muscle,  and  clear  away  the  tissues 
with  a  blunt-pointed  instrument.  The  artery,  with  its  vense  comites, 
will  be  seen  in  front  of  the  libers  of  the  triangularis  sterni,  which  sepa- 
rates it  fi'om  the  pleura  on  the  right  and  the  mediastinum  on  the  left 
side.  In  separating  the  veins  from  the  artery,  care  should  be  taken 
not  to  break  through  the  tliin  structui-e  between  the  vessel  and  the 
cavity. 

The  other  branches  of  the  subclavian  artery  do  not  require  especial 
consideration.  The  inferior  thyroid  is  often  tied  in  the  removal  of 
goitre.  I  have,  in  six  operations,  found  and  deligated  it  prior  to  ab- 
lation of  a  bronchocele.  It  ^vill  usually  be  seen  on  the  tracheal  side 
of  the  common  carotid,  just  below  the  anterior  belly  of  the  omo- 
hyoid. 

Ligation  of  the  Axillary  Artery — Anatomy. — This  artery  may  be 
tied  at  any  i)art  of  its  course.  On  account,  however,  of  the  difficulty  of 
approach  of  that  portion  beneath  the  pectoralis  minor,  it  is  usually 


256 


A  TEXT-BOOK   ON  SURGERY. 


secured  in  the  axilla,  below  this  point,  or  between  the  npper  margin  of 
this  muscle  and  the  lower  border  of  the  first  rib. 

Operation. — AVith  the  head  thrown  back  and  the  shoulders  elevated, 
allow  the  arm  to  remain  by  the  side  of  tlie  body.  About  two  inches  from 
the  sternal  end  of  the  clavicle,  and  half  an  inch  below  its  inferior  border, 
carry  an  incision  outward,  parallel  with  this  bone,  a  distance  of  from 
three  to  four  inches.  This  incision  may  divide  a  sui)erticial  vein  which 
passes  from  the  cephalic  over  the  clavicle.  The  clavicular  libers  of  the 
pectoralis  major  and  the  costo-coracoid  mend)rane  are  divided  ui)on 
the  director.  The  axillary  vein  will  then  be  seen  in  the  auteiior  por- 
tion of  the  wound,  lying  in  front  of  the  artery,  which  may  be  felt  to 
pulsate,  or  seen  Just  external  to  it.  More  extcrniil  still  may  be  seen 
the  anterior  cord  of  the  brachial  plexus,  while  in  the  lower  poition  of 
the  wound  the  cephalic  vein  crosses  over  to  empty  into  the  axillary, 
below  the  clavicle.  Beneath  the  clavicle  the  subclavius  muscle  may 
be  seen.  The  needle  should  be  passed  from  before  backward.  If 
necessary,  a  second  incision  may  be  made,  beginning  in  the  center  of  the 
first  and  carried  in  the  direction  of  the  axilla,  as  recommended  by  Cham- 
berlain. 

This  operation  is  somewhat  more  difficult  than  ligation  of  the  stih- 
clavian  in  its  third  division,  but  it  is  preferable,  on  account  of  being 
farther  removed  from  the  heart.  Delpech  advised  an  incision  beginning 
at  the  junction  of  the  middle  and  outer  third  of  the  clavicle,  and  sepa- 
rating the  deltoid  and  pectoralis  muscles. 

Operation  below  the  Pectoralis  J//«o/\— Shave  and  cleanse  the  axilla, 
and  extend   the  arm  at  a  right  angle   to  the  body.     Divide  the  dis- 


Fia.  294. — Ligution  of  the  axillary  in  its  lower  third, 


tance  between  the  two  folds  of  the  axilla  into  thirds,  and  the  junction 
of  the  anterior  and  middle  thirds  will  indicate  the  position  of  the  artery. 
On  this  line  make  an  incision  in  the  axis  of  the  arm,  well  up  into  the  ax- 
illa.    Cutting  through  the  sldn  and  fasciie,  the  contents  of  this  space  will 


LIGATION  OF   ARTERIES. 


257 


be  seen.  The  vein  lies  internal  to 
the  artery,  often  overlapping  it,  and 
should  1)6  drawn  carefully  backward. 
The  median  nerve  overlies  the  artery, 
or  is  on  its  anterior  aspect,  and 
should  be  drawn  forward  when  the 
needle  is  passed  from  behind  forward 
(Fig.  294). 

Ligation  of  the  BracTiial  Artery 
— Anatomy. — This  artery  lies  in  the 
furrow  along  the  inner  border  of  the 
coraco-brachialis  and  biceps  muscles, 
tending  more  and  more  to  the  front 
as  it  nears  the  elbow-joint.  In  the 
lower  half  or  three  fourths  of  its 
course  it  has  its  venae  comites  on 
either  side,  with  occasional  commu- 
nications across  the  track  of  the  ar- 
tery. The  median  nerve  crosses  it 
by  the  front,  from  the  outer  side, 
on  its  way  to  the  forearm,  while 
the  basilic  vein  is  well  to  the  in- 
ner side.  As  this  vein  passes  up 
toward  the  axilla  it  pierces  the  deep 
fascia,  and  lies  on  the  inner  side  and 
close  to  the  artery.  Joining  with  the 
venae  comites  to  form  a  single  large 
trunk. 

Operation. — A  line  drawn  from 
the  junction  of  the  middle  and  ante- 
rior thirds  of  the  axillary  space  (as 
above  given)  to  the  middle  of  the 
elbow-joint,  in  front,  will  pass  over  the 
brachial  artery  in  its  entire  length. 
The  place  of  election  is  the  middle  of 
the  arm.  At  this  point  make  an  in- 
cision, three  inches  in  length,  over 
the  artery  and  in  its  axis.  Divid- 
ing the  skin  and  deep  fascia,  the 
white  cord  of  the  median  nerve  will 
be  first  seen,  on  the  outer  side  of  the 
lirachial,  overlapping  the  comjjanion 
vein  on  this  side.  Just  internal  to 
this  is  the  artery,  with  the  other  ac- 
companying vein  and  the  basilic  in 
close  relation  (Fig.  295).  The  liga- 
ture should  be  passed  from  the  in- 
ner toward  the  outer  side.  The  op- 
IT 


Fio.  295.  — Ligiitioa  of  the  biiK-liial  oear  the 
middle  and  the  lower  third. 


258  A  TEXT-BOOK   ON  SURGERY. 

eration  above  this  i^oint  is  essentially  the  same.  lu  the  lower  third 
of  the  arm  proceed  as  follows :  On  a  level  with  the  condyles  of  the 
Immenis,  and  between  the  median  basilic  vein  and  the  tendon  of  the 
biceps,  commence  an  incision,  which  is  carried  upward  three  inches 
in  the  brachial  line.  Cutting  througb  the  deep  fascia,  the  artery  is 
readily  found  to  the  radial  side  of  the  median  nerve,  and  surround- 
ed by  its  veins  (Fig.  297).  The  needle  is  passed  from  the  inner  side. 
Occasionally  the  brachial  artery  is  double,  while  more  frequently  it 
bifurcates  into  the  radial  and  ulnar,  at  a  varying  distance  above  the 
elbow. 

Ligation,  of  the  Ulnar  and  Radial  Arteries. — The  radial  artery 
may  be  tied  immediately  above  the  Avrist,  or  in  the  upper  third  of 
the  arm. 

Operation  at  tlie  Wrist. — A  vertical  incision,  one  inch  and  a  half 
long,  is  made  in  the  center  of  the  depression,  between  the  outer  bor- 
der of  the  radius  and  the  radial  border  of  the  extensor  carpi  radialis 
muscle.  Immetliately  beneath  the  deep  fascia  the  artery  will  be  ob- 
served, -with  its  vence  comites,  from  which  it  is  separated  and  tied 
(Fig.  296). 

To  tind  the  artery  in  the  upper  third,  draw  a  line  from  the  middle 
of  the  elbow-joint,  in  front,  to  the  styloid  process  of  the  radius.  Along 
this  line  make  an  incision,  about  three  inches  in  length,  avoiding  the 
supeiiicial  veins,  if  possible.  Cutting  directly  down,  the  artery  will  he 
found  between  the  supinator  longus  externally  and  the  pronator  radii 
teres  on  the  idnar  side.  The  radial  nerve  is  well  to  the  radial  side,  and 
the  venpe  comites  on  either  side  (Fig.  297). 

The  ulnar  artery  may  be  tied  at  the  bend  of  the  elbow,  and  near  the 
wrist.  As  it  passes  beneath  the  pronator  radii  teres  and  Hexor  muscles, 
it  is  so  deeply  situated  that  an  attempt  to  deligate  it  here  is  not  justifi- 
able. Above  this  point  it  may  be  secured  by  a  downward  extension  of 
the  incision  given  for  Kgature  of  the  brachial  at  the  bend  of  the  elbow 
(Fig.  297). 

Near  the  wrist- joint  an  incision  should  be  made  about  a  quarter  of 
an  inch  to  the  radial  side  of  the  tendon  of  the  flexor  carpi  idnaris  miiscle. 
This  incision  should  commence  one  inch  above  the  level  of  the  pisiform 
bone,  and  extend  upward  one  inch.  The  ulnar  nerve  will  be  seen  jjartly 
concealed  by  the  tendon,  while  the  artery  and  its  accompanying  veins 
are  immediately  on  its  radial  side  (Fig.  296). 

Ligation  of  the  Intercostal  Arteries — Anatomy. — The  artery  lies  be- 
hind and  near  the  lower  border  of  the  rib,  the  vein  above,  and  the  nerve 
below  it.  From  near  the  angle  of  the  rib  to  the  vertebral  column  it  is 
separated  from  the  thoracic  cavity  by  the  pleura  alone,  but  in  front  of 
this  it  runs  between  the  two  layers  of  intercostal  muscles. 

Operation. — An  incision  should  be  made  just  along  the  lower  bor- 
der of  the  rib.  After  passing  through  the  outer  plane  of  intercostal 
muscles  the  artery  may  be  seen  and  secured.  Or,  failing  in  this, 
take  a  long,  curved  aneurism-needle,  and  through  a  puncturf^  near 
the  lower  border  of  the  rib  pass  it  behind  the  artery  and  around  the 


LIGATION   OF  ARTERIES. 


259 


^ 

M 


3? 


Fig.  296. — Lipration  of  tlie  ulnar  aud  radial 
arteries  of  the  wrist. 


Fig.  297.— Lifsition  of  the  radial  in  the  middle  of  the 
forearm  and  of  the  brachial  at  tlie  bind  of  the  elbow. 


260  A  TEXT-BOOK  ON   SURGERY. 

rib,  taking  care  not  to  imnctuie  the  pleurii.  Wlu'u  tlie  point  of  the 
needle  is  felt  at  the  upper  margin  of  the  bone,  another  punctnre  is 
made  to  allow  its  escape.  The  needle  is  now  armed  with  a  strong  cat- 
gut and  withdrawn.  A  pellet  of  sublimate  gauze  is  laid  over  the  skin, 
between  the  points  of  exit  and  entrance,  around  which  the  ligature  is 
tied.  In  excei^tional  cases  it  may  be  necessary  to  remove  a  portion  of 
the  rib. 

Ligation  of  the  Abdominal  Aorta — Anatomy. — The  aorta  iisually 
bifurcates  upon  the  body  of  the  fourth  lumbar  vertebra,  a  little  to 
the  left  of  the  median  line.  This  point  is  on  a  level  with  the  high- 
est point  of  the  iliac  crests,  and  is  a  little  to  the  left  of  and  below 
the  umbilicus.  The  point  of  election  is  one  inch  above  the  bifurca- 
tion. 

Operation,  3fedian. — In  the  linea  alba  make  an  incision,  six  inches 
long,  the  center  of  which  corresponds  to  the  umbilicus.  "When  within 
an  inch  of  the  navel,  curve  to  the  left  three  fourths  of  an  inch,  aiid  one 
inch  farther  on  regain  tbe  middle  line.  Divide  all  the  tissues  down  to 
the  parietal  peritonseum,  and  then  arrest  all  bleeding  before  opening  this. 
After  opening  into  the  cavity,  the  transverse  colon  should  be  displaced 
upward,  and  the  small  intestines  brought  out  through  the  wound  and 
secured  in  a  soft  rubber  cloth,  kept  wai-m  with  sublimate  towels.  With 
the  finger-nail  or  a  blunt  director  scratch  through  the  peritonjpum  and 
expose  the  aorta,  around  which  a  large  animal  t^or  silk)  ligature  should 
be  passed  from  the  right  side. 

Lateral  Incision. — From  the  free  end  of  the  left  eleventh  rib  com- 
mence an  incision,  which  carry  downward  to  ^\^thin  three  fourths  of  an 
inch  of  the  antei'ior  superior  iliac  spine,  thence  i)arallel  with  Poupart's 
ligament  to  its  middle.  Divide  the  three  abdominal  muscles  down  to 
the  parietal  peritonseum.  When  this  is  reached,  use  the  lingers,  the 
nails  of  which  have  been  closely  pared,  and  lift  the  ])eriton,'eum  from  the 
posterior  abdominal  wall.  Passing  over  the  posterior  iliac  crests  and  into 
the  iliac  fossa,  the  ridge  formed  by  the  psose  muscles  is  reached  and 
must  be  crossed.  The  lumbar  nerves  and  ureter  should  be  avoided,  and, 
by  a  free  dilatation  of  the  wound  and  concentration  of  light,  the  aorta 
may  be  seen  and  tied,  about  three  inches  above  the  lumbo-sacral  junc- 
tion. Of  these  two  procedures  the  former  is  anatomically  and  surgically 
preferable.  * 

Ligation  of  the  Common  Iliac  Artery — Anatomy. — The  common 
iliac  arteries  extend  from  the  left  side  of  the  body  of  the  fourth  lum- 
bar to  the  sacro-lumbar  junction.  It  is  crossed  by  the  iireter  in  front, 
near  its  bifurcation,  and  by  some  filaments  of  the  sympathetic  nerve 
higher  up.  The  left  common  iliac  vein  lies  wholly  internal,  and  is 
on  a  plane  somewhat  deeper  than  the  artery.  The  inferior  mesen- 
teric vein  crosses  the  left  artery,  but  is  within  the  peritoneal  folds. 
The  right  iliac  artery  crosses  in  front  of  both  the  iliac  veins,  passing 
at  a  right  angle  to  the   left  vein  and  obliquely  over  the  right,  until 

*  The  abdominal  aorta  has  been  tied  ten  times,  all  fatal. 


LIGATION   OF  ARTERIES. 


261 


near  its  termination  the  artery  is  in  front  of  and  external  to  the  vein 

(Fig.  298). 

Operation — Anterior  Incision. — Make  an  incision  in  the  linea  alba  ex- 
tending from  about  one  inch  above  to  about  live  inches  below  the  umbili- 
cus. Avoid  the  umbilicus  as  directed  in  the  ligation  of  the  aorta.  Arrest 
all  bleeding  before  the  parietal  peritongeum  is  opened.  When  this  is  done, 
di-aw  the  small  intestines  out  through  the  wound  and  protect  them  in  a 


Fig,  298. — Dissection  showint'  the  relation  of  the  right  common  external  and  internal  iliac  arteries  and  reins. 
The  ureter  is  seen  crossing  the  iliac  near  the  biitircation. 


soft,  clean  rubber  cloth,  kept  warm  by  sublimate  towels.  The  posterior 
wall  of  the  peritonaeum  is  scratched  through  by  means  of  two  dissecting- 
forceps  and  the  aneurism-needle  passed  from  A\ithin  out. 


262 


A  TEXT-BOOK   ON   SURGERY. 


Lateral  Incision. — Same  as  for  the  aorta.*  The  anterior  incision  is 
preferable. 

Liffation  of  the  Infernal  and  External  Iliac  Arteries — Anatomy. — 
The  internal  iliac  artery,  less  than  two  inches  in  length,  has  the  ureter 
in  front,  its  accompanying  vein  and  the  lurabo-sacral  nerve  behind. 

Operation.  —  Throtir/Ji  the  Peritonaum.  —  Proceed  as  in  the  same 
operation  for  the  primitive  iliac.  If  necessary,  a  transverse  incisicm 
may  be  added  to  that  in  the  linea  alba. 

Betiind  tJte  Peritona'inn. — One  inch  and  a  lialf  internal  to  the  anterior 
superior  spine  of  the  ilium  begin  an  incision,  which  travels  downward 
and  inward  across  the  track  of  the  external  iliac.  Be  careful  not  to  carry 
the  deep  incision  far  enough  internally  to  divide  the  epigastric  artery. 
Cut  down  to  the  parietal  peritonaeum,  and  separate  this  from  its  attach- 


Fio.  299. — Ligation  of  the  gluteal,  internal  pudic,  and  sciatic  arteries. 


*  This  artery  has  been  tied  about  seventy  times.     For  anenrism  aboat  33  per  cent  recovered, 
while  for  hsemorrhage  almost  every  case  ended  fatally. 


LIGATION  OF   ARTERIES. 


263 


ment  to  the  abdominal  wall  and  iliac  fossa,  along  the  iliac  artery.  When 
the  bifurcation  is  reached,  draw  firmly  with  a  retractor  upon  the  upper 
lip  of  the  wound  and  pass  the  needle  from  the  inner  side.*  This  opera- 
tion may  be  demanded  in  sciatic  or  gluteal  aneurism,  or  hsemon-hage 
from  these  vessels.     The  fonner  method  is  preferable. 

The  Gluteal  Artery. — Make  a  five-inch  incision,  on  a  line  extending 
from  the  spine  of  the  last  lumbar  vertebra  to  the  trochanter  major.  The 
center  of  this  line  wiU  indicate  the  point  at  which  the  artery  emerges. 
Separate  with  a  dull  instrument  the  fibers  of  the  gluteus  maximus,  dis- 
place anteriorly  the  gluteus  medius,  and  find  the  groove  between  the 
minimus  and  the  pyriformis.  Follow  this  groove  upward  to  the  bony 
edge  of  the  notch,  and  the  artery  and  veins  will  be  found  (Fig.  299,  upper 
incision). 


i 


Fio.  300.— Ligation  of  the  internal  pudic  in  the  perinseum. 

The  Sciatic. — Make  an  incision,  five  inches  long,  on  a  line  from  the 
middle  of  the  sacral  spines  to  the  trochanter  major.  Separate  the  fibers 
of  the  gluteus  maximus  and  find  the  lower  border  of  the  pyriformis.     The 

*  The  internal  iliac  has  been  tied  about  thirty  times,  with  a  death-rate  of  66  per  cent. 


264 


A  TEXT-BOOK  ON   SURGERY. 


great  cord  of  the  sciatic  nerve  will  now  be  seen  emerging  from  beneath 
the  muscle,  and  Immediately  in  front  of  this  the  small  sciatic  nerve  and 
the  sciatic  artery.  The  iiitentdl  jnidfc  artery  is  Just  anterior  to  this, 
upon  the  spine  of  the  ischium  (Fig.  299,  middle  incision).  The  sciatic 
artery  may  also  be  secured  opposite  the  ttiber  ischii,  along  the  outer  bor- 
der of  which  it  runs  (Fig.  299,  lower  incisi(m). 

The  Internal  Fadic  in  the  Perinccum. — With  the  patient  sujiine 

and  the  thigh  abducted, 
make  an  incision  in  a  line 
with  the  symphysis  pubis 
and  tuber  iscliii.  The 
artery  will  be  found  as 
it  runs  along  the  inner 
margin  of  the  ramus  of 
the  pul)is  (Fig.  300). 

Ligation  of  the  Ex- 
ternal Iliac  in  its  Loioer 
Portion. — The  external 
■iliac  has  in  relation  to  it 
the  accompanying  vein 
internally.  The  spermat- 
ic vessels  cross  it,  and  in 
the  male  the  vas  deferens 
is  internal  to  it  at  the  in- 
guinal ring. 

Operation. — One  inch 
to  the  Inner  side  of  the 
anterior  superior  spine 
of  the  ilium  commence 
an  incision,  which  is  car- 
ried in  the  direction  of 
the  middle  of  Potipart's 
ligament,  and  terminates 
one  inch  above  this  point, 
without  entering  the  in- 
ternal ring.  Divide  the 
three  muscles  down  to 
the  transversalis  fascia, 
arrest  all  bleeding,  divide 
the  fascia  carefully,  re- 
tract the  upper  lip  of  the 
wound,  and  lift  the  peri- 
toneeum  from  the  iliac 
fossa  and  artery  (Fig.  301).  Displace  any  overlying  lymphatics  and  in- 
troduce the  needle  from  the  inner  side.* 


Fi. 


301. — Ligation  of  the  external  iliac  in  its  lower  portion,  and 
of  the  femoral  in  Hunter's  caual. 


*  Ligation  of  the  external  iliac  li.is  proved  fatal  in  almost  every  instance  in  which  it  was  tied 
for  hajmorrhage.     For  aneurism  about  07  per  cent  recover. 


LIGATION  OF  ARTERIES. 


265 


The  deep  circumflex  and  the  epigastric  branches,  which  arise  about 
half  an  inch  above  the  ligament,  may  also  be  tied  by  this  incision.  In 
its  upper  portion  this  vessel  may  be  secured  by  the  same  operation  as  for 
the  commcjn  iliac. 

Ligation  of  the  Femoral  Artery — Anatomy. — At  Ponpart's  ligament 
the  vein  is  on  the  same  plane  as  the  artery,  and  immediately  internal  to 
it.  One  quarter  of  an  inch  to  the  outer  side,  and  deeper  than  the  artery, 
lies  the  anterior  crural  nerve.  'One  inch  and  a  half  from  the  ligament  the 
2yrnfitndn  femoris  arises  from  the  outer  aspect  of  the  common  trunk, 
and  from  one  to  two  inches  lower  passes  behind  the  superficial  femoral. 
Pour  inches  fi'om  Poupart's  ligament  the  relations  have  changed  to  such 


x\< 


Fig.  302. — Ligation  of  the  superficial  femoral  in  Scarpa's  space. 

an  extent  that  the  femoral  vein  is  deeper  and  slightly  behind  the  artery. 
Tlie  long  saphenous  nerve  lies  upon  the  sheath  of  the  artery,  in  its  middle 
third,  and  occasionally  sends  a  branch  through  Huntefs  canal.  The 
sartorius  muscle  covers  the  femoral  artery  in  all  of  its  course  except  the 
first  four  inches,  where  it  is  superficial. 

Operation. — A  line  from  a  point  half  way  between  the  symphysis 
pubis  and  the  anterior  superior  spine  of  the  ilium  to  the  internal  condyle 


266 


A  TEXT-BOOK   ON  SURGERY. 


of  the  femur  will  run  over  and  parallel  with  the  femoral.     It  may  be 
secured  in  any  part  of  its  course. 

1)1  Scar/>a-f>  Space. — The  point  of  election  for  tying  the  su]ierricial 
femoral  is  from  four  to  live  inches  below  Poupart's  ligament.  AVitli  this 
as  the  center,  make  an  incision  three  inches  long  on  the  line  already  indi- 
cated. Beneath  the  skin  and  fascia  some  superficial  and  unimi)ortant 
vessels  may  be  divided  ;  the  libers  of  the  sartorius  will  be  seen  in  the 
lower  portion  of  the  wound,  and  should  be  drawn  downward  with  a  re- 
tractor. The  sai)henous  nei've  will  next  be  seen  on  the  outer  side  of  the 
common  sheath  of  the  vessels.  The  sheath  should  next  be  incised,  and 
the  artery  carefully  isolated  by  inserting  a  dull  director  beneath  and 
around  it  from  the  inner  side.     The  ligature  is  passed  the  same  way. 


Fio.  303. — Ligation  of  the  deep  and  superficial  femoral  near  the  bifurcation  of  the  common  femoral,  and 

in  tlie  apes  of  Scai-pa'.s  triangle. 

In  this  same  plane  an  incision  may  be  made  to  expose  the  artery 
lower  down,  where  it  is  completely  hidden  by  the  sartorius.  This  mus- 
cle may  be  drawn  to  the  side  most  convenient  to  the  operator  (Figs. 
302,  303). 

In  Hunter* s  Canal. — Find  the  junction  of  the  middle  and  lower  thirds 
of  the  thigh.  In  the  femoral  line,  with  this  point  as  the  center,  make  an 
incision,  about  four  inches  in  length,  directly  down  to  the  sheath  of  the 


LIGATION   OF  ARTERIES. 


267 


sartoriiis,  which  is  incised  and  the  muscle  displaced  outward.  Imme- 
diately upon  opening  the  posterior  layer  of  the  sheath  of  the  muscle,  the 
oblique  aponeurotic  lil)ers  which  pass  from  the  adductor  magnus  to  the 
vastus  internus — fonning  the  anterior  wall  of  Hunter's  canal— are  seen. 
These  may  be  divided  on  a  director,  or  the  sheath  opened  half  an  inch 
above  this  point.  The  saphenous  nerve  is  on  the  sheath,  and  the  vein  is 
behind  and  to  the  outer  side  (Fig.  304). 

The  Common  Femoral  above  the  Profunda. — Make  an  incision  in  the 
femoral  line,  from  three  fourths  of  an  inch  above  Poupart's  ligament 
downward  for  three  inches  and  a  half.  Do  not  divide  the  ligament,  but 
approach  the  artery  one  half  inch  below.  The  superficial  epigastric 
vein  and  artery  may  be  wounded. 
Divide  the  fascia  lata,  and  pass  the 
ligature  fi'om  within  out.  (Dissec- 
tion shown  in  Figs.  302,  303.) 

The  Profunda  Femoris.  — 
Make  an  incision  in  the  femoral 
line,  three  inches  and  a  half  long, 
the  center  opposite  a  point  one 
inch  and  a  half  to  two  inches  below 
Poiipart's  ligament.  As  above, 
approach  the  common  trunk  and 
search  along  its  outer  border  for 
the  origin  of  the  profunda*  (Fig. 
303).  Pass  the  ligature  from  with- 
in out,  one  inch  from  its  origin. 
Avoid  the  branches  of  the  ante- 
rior crural  nerve. 

In  wounds  of  the  posterior  fem- 
oral region  it  may  be  necessary 
to  tie  this  vessel  as  well  as  for 
aneurism.  Ligation  of  the  com- 
mon femoral  is  rarely  called  for, 
and  should  only  be  done  in  ex- 
treme cases.  In  modern  surgical 
practice,  deligation  of  the  super- 
ficial femoral  is  comparatively  free 
from  danger. 

Ligation  of  the  Popliteal — 
Operation. — Place  the  patient  on 
his  belly,  with  the  popliteal  space 

looking  upward.  Make  an  incision,  four  inches  long,  beginning  two 
inches  and  a  half  above  the  level  of  the  joint,  at  the  outer  edge  of  the 
semi-membranosus  tendon,  and  extending  down  through  the  middle  of 
the  space.     Dividing  the  dense,  deep  fascia,  the  areolar  tissue  which  sur- 


FiG.  311-1.  — LiL'ation  of  tlie  popliteal  artery.    Kelations 
of  contents  in  the  left  lower  extremity. 


*  In  a  large  majority  of  subjects  I  have  found  this  branch  given  oif  one  inch  and  a  half  be- 
low the  ligament. 


268 


A  TEXT-BOOK   ON  SURGERY. 


rounds  the  vessels  and  nerves  of  the  space  will  be  seen,  and  at  the  same 
time,  and  superficially,  the  popliteal  nerve.  Draw  this  and  the  vein 
which  is  immediately  below  outward,  and  the  artei'y  will  be  seen  deeply 
situated,  and  in  the  upper  part  of  the  space  internal  to  the  vein.  Lower 
down  the  relations  change,  the  nerve  crossing  sujierlicial  to  the  vein, 
and  this  overlying  the  artery  (Fig.  304). 

Ligation  of  the  Posterior  Tibial  Artery  at  the  Middle  of  tlie  Leg. — 
Make  an  incision,  half  an  inch  from  and  parallel  with  the  inner  margin  of 
the  tibia,  three  inches  and  a  half  long.    Avoid  the  internal  sai)henous  vein. 

After  passing  the  deep  fascia, 
look  for  the  lower  tibial  fibers 
of  the  soleus.  which  pass  ob- 
liquely fixmi  this  border  of  the 
tibia  backward  and  slightly 
downward.  Divide  these  on  a 
director,  and  with  the  finger 
separate  the  sural  from  the 
flexor  muscles.  Eetracting  the 
edges  of  the  wound,  the  artery 
will  be  seen,  with  a  vein  on 
either  side  and  the  posterior 
tibial  nerve  lying  just  behind. 
The  vessels  are  held  down  by 
the  common  sheath  of  the  deep 
muscles  (Fig.  305). 

Opposite  the  Ankle-joint. — 
Half  way  from  the  tip  of  the 
internal  malleolus  to  the  ante- 
rior edge  of  the  tendo  Achillis 
commence  an  incision,  which 
extends  directly  upward  for  one 
inch  and  a  half.  Dividing  the 
skin  and  fascia  upon  a  director, 
cut  the  dense  internal  annular 
ligament.  The  artery,  with  its 
two  veins,  will  be  found  with 
the  posterior  tibial  nerve  and 


Fig.  305. — Ligatiou  of  the  posterior  tibial  above  the  malleolus. 


tendon  of  the  flexor  longus  pollicis  behind,  and  the  flexor  longus  digito- 
rum  and  tibialis  posticus  in  front.     As  the  artery  curves  around  the  mal- 


LIGATION   OF  ARTERIES. 


269 


leolus  it  will  be  found 
one  third  the  distance 
from  the  tip  of  the  mal- 
leolus to  the  convexity 
of  the  heel. 

The  Anterior  Tibial 
at  t7ie  Middle  of  tJie  Leg. 
— A  line  from  a  point 
half  way  between  the 
anterior  tuberosity  of 
the  tibia  and  the  head 
of  the  fibula  to  a  like 
point  between  the  two 
malleoli,  in  front  of  the 
ankle,  \^"ill  indicate  the 
j)Osition  of  this  artery. 
At  the  middle  of  the 
leg  make  a  four-inch 
incision  in  this  line,  di- 
viding everything  down 
to  the  dense  fascia  im- 
mediately over  the  mus- 
cles. Split  this  on  a  di- 
rector and  dissect  it  up 
carefully,  searching  for 
the  interspace  between 
the  tibialis  anticus  in- 
ternally and  the  exten- 
sor proprius  pollicis  ex- 
ternally. Finding  this, 
discard  the  knife,  and 
with  the  finger  sepai-ate 
the  muscles,  and  the  ar- 
tery, veins,  and  nerve 
will  be  found  deep  down 
upon  the  interosseous 
membrane,  the  nerve  be- 
ing external  and  slight- 
ly in  front,  and  the 
veins  wound  about  the 
artery.  In  order  to  re- 
lax the  muscles  and  ad- 
mit the  light,  flex  the 
tarsus  on  the  leg  (Fig. 
306). 

At  tTie  Lower  Por- 
tion.— One  inch  above 
the  tip  of  the  internal 


Fio.  306. — Ligation  of  the  anterior  tibial  in  the  muldlc  and  lowet 
tliird  of  the  leg,  and  of  the  dorsalis  pedis  artery. 


270  A  TEXT-BOOK   ON   SURGERY. 

malleolus  begin  :in  incision,  and  carry  it  two  inches  npward,  in  the  tibial 
line  above  given.  This  incision  is  along  the  fibular  border  of  the  exten- 
sor pollicis,  between  which  and  the  tendon  of  the  extensor  communis 
digitorum  the  artery  will  be  found,  with  the  nerve  on  the  iibular  sitle, 
and  its  companion  veins  on  either  side. 

The  Dorf<alis  Pedis. — One  fourth  of  an  inch  to  the  fil)ular  side  of  and 
parallel  with  the  tendon  of  the  extensor  x'ollicis  nuike  an  incision,  one 
inch  long,  over  the  tarsus.  The  artery  and  veins  will  be  seen  on  a  plane 
slightly  deeper  than  the  tendon,  with  the  nerve  on  the  tibial  side  of  the 
vessels.  This  line  is  a  continuation  upward  of  the  first  metacarxtal  inter- 
space (Fig.  306). 


CHAPTER  XII. 

THE   SURGICAL  DISEASES   AXD   SURGERY   OF  THE  BONES. 

Ostitis. — Inflammation  in  bone  may  be  arute  or  cJironic^  general  or 
circnmscribed,  traumatic  or  idiopathic.  It  may  involve  the  periostei\m 
{periostitis),  the  compact  substance  {ostitis),  or  the  cancellous  tissue  and 
medulla  {endustitis).  Endostitis  and  periostitis  may  occur  independ- 
ently, yet  ostitis,  more  or  less  severe,  must  of  necessity  be  a  part  of  a 
pronounced  inflammation  of  either  the  periosteum  or  the  endosteum  and 
medulla. 

The  termination  of  inflammation  in  lione  is  in  resolution  or  local 
death.  In  resolution  the  inflammatory  embryonic  tissue  undergoes 
granular  metamorphosis  and  is  absorbed,  or  it  may  be  in  part  converted 
into  new  bone.  If  the  bone  dies,  it  may  be  cast  off  as  a  sequestrum,  or 
remain  imprisoned  in  a  shell  of  new-made  osseous  tissue,  the  involucrum. 

When  the  inflammatory  process  is  severe,  or  the  arrest  of  nutrition 
sudden  and  complete,  necrosis,  or  death  in  mass,  occurs ;  under  other 
and  milder  conditions  of  death  in  bone,  the  process  of  dissolution  is 
known  as  caries. 

In  necrosis,  Avhich  is  aptly  compared  to  gangrene  of  the  soft  tissues, 
the  cast  off  portion  retains  something  of  its  original  form  and  character  ; 
in  caries,  which  is  the  molecular  death,  or  ulceration  of  bone,  the  cell- 
elements  disappear  by  granular  degeneration,  leaving  no  trace  of  the 
original  structure. 

Pathology. — When  a  bone  is  subjected  to  irritation  by  a  force  applied 
from  without,  or  an  interference  with  its  normal  process  of  nutrition 
from  within,  the  earliest  change  which  occurs  is  hypercEmia,  with  mai'ked 
increase  in  the  number  of  white  blood-corpuscles.  With  the  dilatation 
of  the  blood-vessels,  and  escai)e  of  the  leucocytes  into  the  extra-vascular 
spaces,  cell-activity  becomes  general.  Rapid  proliferation  occurs  in  the 
cells  of  the  periosteum  ;  the  medullo-cells  nnd  the  myeloplaxes,  found 
not  only  in  the  central  marrow,  but  around  the  vessels  in  the  Ilavei'sian 
canals ;  the  connective- tissue  cells  and  the  bone-corpuscles.  The  result 
of  this  general  proliferation  is  a  mass  of  protoplasm  or  embryonic  cells 
analogous  to  that  described  in  the  chapter  on  Inflammation. 

Coincident  with  the  formation  of  this  embryonic  tissue,  absorption  of 
the  surrounding  and  contiguous  osseous  lamelL'e  occurs,  giving  rise  to 
abnormal,  and  often  multiple  and  communicating,  cavities,  known  as  the 


272  A  TEXT-BOOK  ON  SURGERY. 

caverns  of  Howship.  The  cause  oJ"  this  absorption  can  not,  as  yet,  be 
satisfactorily  explained. 

Up  to  this  point  in  the  process  of  inflammation  tlie  pro,<:;ress  is  practi- 
cally the  same  in  all  forms  of  ostitis,  whether  acute  or  chronic,  traumatic 
or  idiopathic. 

If  the  ostitis  is  mild  in  character,  and  the  tissues  involved  are  in 
proper  condition  to  resist  disease,  a  portion  of  the  mass  of  emlnyonic 
cells  disappears  by  absorption,  while  the  remainder  becomes  converted 
into  new  b(me,  which  new  formation  is  compcnsatoi-y  to  the  loss  of  tissue 
in  the  earlier  stages  of  the  iiitlammatioii.  This  result  may  occur  in  the 
periosteum,  compact  tissue,  or  endosteum. 

In  exceptional  cases  the  process  of  embryonic  tissue-formation  and 
absorption  of  the  lamellje  goes  on  indefinitely  until  the  bone  is  more  or 
less  completely  destroyed  and  replaced  by  granulation-tissue.  This  va- 
riety is  known  as  rarefying  ostitis  {ostitis  rdrffacien-s). 

When,  in  the  process  of  repair,  the  new  formation  of  bone-tissue  is  in 
excess  of  the  original  structure,  it  is  termed  productive  ostitis  {ostitis 
osteoplast ica).  In  some  of  these  new  formations  or  exostosrs  the  osseous 
structure  resembles  closely  the  parent  bone,  while  in  others  the  new 
product  is  more  dense  and  ebuniated.  To  this  variety  the  name  of  ostitis 
sclerosa  has  been  given. 

Productive  ostitis  and  ostitis  sclerosa  occur  usually  in  the  l)ones  of 
the  cranium  and  in  the  compact  substance  of  the  long  hemes.  In  rare 
instances  the  medullary  cavity  is  filled  with  newly  formed  bone.  If  the 
inflammatory  process  is  intense,  and  the  condition  of  the  tissues  favorable 
to  its  development,  not  only  the  compact  substance,  but  the  medulla  and 
cancellous  tissue  becomes  rapidly  infiltrated  with  pus,  inducing  a  more 
or  less  extensive  necrosis.  This  condition  is  termed  osteo-myelitis.  Sup- 
puration is  especially  apt  to  occur  in  ostitis  affecting  the  spcmgy  bones, 
as  those  of  the  tarsus  and  carpus,  the  terminations  of  the  long  bones,  and 
the  bodies  of  the  vertebra?,  although  cases  are  not  infrequently  observed 
in  which  the  embryonic  granulation-tissue  has  filled  the  space  fonnerly 
occupied  by  the  spongy  substance,  and  in  which  no  pus  is  present  {ostitis 
interna  fiingosa).  The  inflammatory  tissue  occasionally  undergoes 
caseous  degeneration  {ostitis  interna  caseosa),  and  in  still  rarer  instances 
miliary  tubercles  are  found  in  old  inflammatory  centers  {tubercular 
ostitis). 

Causes.  —  Inflammation  of  the  periosteum  and  the  underlying  bone 
may  result  from  direct  or  indirect  violence.  A  fracture  will  jiroduce  a 
tj^ical  acute  ostitis,  while  the  same  result  may  be  secondary  to  an  injury 
of  a  joint.  Traumatic  ostitis  is  almost  always  acute,  Avhile  idiopathic 
inflammation  is  usually  subacute  in  character.  Ostitis  and  periostitis 
occur  chiefly  as  expressions  of  a  dyscrasia.  They  are  frequently  met 
with  in  patients  suffering  from  tuberculosis,  scrofula,  and  syphilis..  Peri- 
ostitis osteoplast  ica,  affecting  the  tibia  and  bones  of  the  calvarium,  re- 
sulting in  nodes  or  exostoses,  is  frequent  in  this  last  disease.  Ostitis  is 
held  by  late  pathologists  to  be  a  frequent  result  of  tiibercular  deposits  in 
the  bones. 


THE  SURGICAL  DISEASES.  273 

It  is  jirobable  that  the  initial  lesion,  in  the  great  majority  of  instances, 
is  the  rupture  of  a  cai^illary,  and  hpemorrhage  in  the  cancellous  tissue. 
It  has  been  shown  )>y  Cornil  and  Ranvier  that  the  protection  of  the  cajal- 
laries,  in  bone  which  is  nndergoing  active  develoi^ment,  is  so  delicient 
that  extravasation  occurs  with  such  frequency  that  tlie  process  may  be 
almost  considered  as  physiological.  This  is  especially  true  of  the  sliort, 
spongy  bones,  the  epiphyseal  regions  of  the  long  bones,  the  sternum, 
and  vertebrae.  If  to  this  be  added  the  fact  that  these  bones  are  the  most 
frequent  seat  of  the  inflammatory  change,  and  that  the  period  of  life  in 
which  ostitis  usually  occurs  is  the  period  of  greatest  nutritive  activity,  it 
is  not  difficult  to  conceive  that  an  extravasation  of  blood  which  would  be 
practically  harmless  in  a  vigorous  and  healthful  condition  of  the  bones 
might  induce  serious  inflammatory  changes  in  tissues  already  deficient  in 
nutrition. 

Si/iitpfoms. — Osteo-periostitis^  whether  acute  or  chronic,  is  usually 
characterized  l)y  pain  at  the  seat  of  inflammation  before  any  tumefaction 
is  recognized.  The  severity  of  the  pain  is  in  proportion  to  the  intensity 
of  the  mcjrbid  process.  It  is  markedly  increased  on  pressiire,  and  is 
usTially  more  severe  at  night.  The  symptoms  of  j^ressure  upon  the  end- 
organs  of  the  sensory  nerves  are  coincident  with  the  remarkably  rapid 
development  of  the  embryonic  tissue  from  proliferation,  chiefly  of  the 
cells  of  the  periosteum,  the  new  formation  lifting  the  covering  from  the 
bone.  The  disease  may  be  ushered  in  with  or  without  a  chill  or  rigors. 
The  exacerbations  of  temperature  are,  as  a  rule,  not  so  high  in  osteo-peri- 
ostiiis  as  in  oafeo-mi/elitis. 

In  this  latter  form  of  ostlfls  the  symptoms  are  more  giave  in  charac- 
ter. The  sense  of  pain  is  deep-seated  and  intense  in  most  instances,  while 
in  all  tlie  febrile  movement  is  high.  The  soft  parts  become  swollen,  red, 
and  ojdematous,  and,  as  a  rule,  septic  absorption  becomes,  in  the  early 
history  of  the  case,  a  prominent  and  dangerous  symptom,  terminating  in 
l)y<pmia,  and  not  infrequently  in  death. 

Treatment. — The  earliest  indication  in  the  treatment  of  acute  perios- 
titis is  rest  in  bed,  with  the  part  involved  in  the  position  of  least  discom- 
fort. Hot  applications,  by  means  of  the  rubber  water-bag,  or  cloths 
dipped  in  hot  water  and  partially  wrung  out,  or  the  cold  ice-bag  or 
cloths,  as  may  seem  most  agreeable  to  the  patient,  will  be  found  of  value. 

When  the  inflammatory  symptoms  are  severe,  as  detennined  by  pain, 
swelling,  and  high  fel)rile  movement,  and  especially  when  the  suspicion 
of  pus  under  the  i)eriosteum  has  been  confirmed  by  exploration  with  a 
good-sized  hypodermic  needle  and  aspirator,  a  free  incision  is  demanded. 
This  procedui'e  should  not  be  delayed,  for  not  infrequently  irreparable 
damage  may  follow  the  lifting  of  the  periosteum  by  tlie  inflammatory 
process.  It  is  better  to  err  on  the  safe  side,  if  the  diagnosis  is  in  doubt, 
and  make  the  incision  down  and  through  to  the  bone,  an  operation  which 
is  exceedingly  simple  when  Esm-.irch's  bandage  is  employed,  and  practi- 
cally free  from  danger. 

All  such  wounds  should  be  filled  with  sublimate-gauze  dressings. 
When  ostitis  exists,  if  the  symptoms  point  to  severe  or  extensive  intiam- 

18 


274  A  TEXT-BOOK  ON  SURGERY. 

mation,  the  trepliine,  rongeur,  gouge,  or  cliisel  should  he  freely  used  to 
effect  easy  escape  to  any  pus  which  may  be  imprisoned  in  the  bony 
tissues.  In  osteo-myelitis  this  method  of  treatment  is  imperative.  Ab- 
scess of  bone  should  be  treated  upon  the  principles  of  immediate  opera- 
tion and  free  drainage. 

When  necrosis  or  caries  is  evident,  the  removal  of  the  dead  tissue  is 
necessary,  since  its  presence  as  a  foreign  body  is  a  constant  menace  to 
the  contiguous  healthy  structures.  A  free  incision  should  be  made,  down 
to  and  along  the  diseased  line,  the  first  and  only  cut  going  down  to  the 
dead  bone,  dividing  the  tliickened  periosteum  with  the  skin.  Then,  with 
the  elevator — preferably  Sayre's  oyster-knife — carefully  peel  up  the  peri- 
osteum until  the  healthy  bone  is  reached.  If  the  dead  bone  can  not  be 
lifted  out  it  should  be  divided  with  the  exsector  or  the  cutting-forceps. 
For  lifting  a  sequestrum  the  forceps  of  Hamilton  or  other  grasjiing  in- 
strument will  suffice.  In  chronic  ostitis  of  the  spongy  substance  Volk- 
mann's  spoon-scraper  is  an  excellent  instrument. 

Osteomalacia — RacTiitis. — Osteomalacia,  sometimes  known  as  mol- 
lities  ossium,  is  a  rare  affection.  .It  is  a  disease  of  adult  life,  and  is 
especially  ai)t  to  occur  in  child-bearing  women.  The  chief  pathological 
change  is  the  disappearance  of  the  earthy  constituents  from  the  bones, 
and  their  presence  in  the  blood  and  excretions  in  abnoi-mal  proportion. 
Softening  is  often  present  to  such  an  extent  that  marked  distortions 
occur  from  muscular  contraction  and  superincumbent  weight.  The  me- 
dulla of  the  bones  is  the  seat  of  congestion,  often  resulting  in  rupture  of 
the  vessels  and  extravasation  of  blood.  In  the  later  stages  the  l)ony 
lamelljE  disappear  by  absorption,  the  process  commencing  from  within. 

The  treatment  consists  in  the  prevention  of  fracture  and  defonnity  by 
proper  precaution,  and  the  restoration  of  the  osseous  system  to  its  normal 
condition  by  generous  diet,  studied  hygiene,  tonics,  and  the  administra- 
tion of  the  hypophosphites  of  lime  and  soda,  with  cod-liver  oil  and  iron. 

Rachitis,  or  '■'ricJcets"  is  a  more  frequent  and  graver  affection.  It  is 
strictly  a  disease  of  childhood  and  youth,  inducing  deformities  more  or 
less  extensive.  Although  it  attacks  the  entire  osseous  system,  its  disas- 
i;rous  effects  are  chiefly  observed  in  the  bones  of  the  skull  and  the  long 
bones  of  the  lower  extremities.  The  bones  of  tlie  skull  become  thickened 
and  prominent,  the  sternum  is  advanced  and  angular  ("pigeon-l)reast "), 
and  the  bones  of  the  lower  extremities  are  curved  antero-posteriorly  or 
laterally.  While  the  diameter  of  a  rachitic  bone  is  usually  increased  at 
all  points,  the  enlargement  is  most  marked  near  the  extremities.  Rickets 
is  a  disease  of  malnutrition.  Its  chief  pathological  feature  is  the  forma- 
tion of  an  eml)i'yonic  tissue,  which  in  normal  condition  is  converted  into 
bone,  but  in  the  i-achitic  diathesis  only  partially  (if  at  all)  undergoes  ossi- 
fication. The  cells  of  the  periosteum  are  xmusually  active  in  this  pro- 
liferation, as  are  the  cartilage  bone-making  cells  ;  yet  this  new  tissue 
remains  in  great  part  embryonic,  without  the  formation  of  the  osseous 
lamellse. 

The  treatment  of  rickets  is,  first,  to  prevent  deformity,  and,  secondly, 
to  relieve  the  dyscrasia.     Rachitic  children  should  be  kept  in  the  recum- 


FRACTURES.  275 

bent  posture,  or,  if  allowed  to  stand  or  walk,  artificial  support  sliould  be 
given  to  the  lower  extremities  and  spine.  The  medical  indications  are 
nutritious  diet,  out-of-door  life,  and  the  administration'of  the  hypophos- 
phites  of  lime  and  soda,  with  cod-liver  oil  and  tonics.  The  correction 
of  the  deformities  which  may  result  from  rickets  will  be  considered  in 
the  article  on  Orthopa?dic  Surgery. 

Fractures. — A  fracture  is  a  sudden  solution  of  continuity  in  bone  or 
cartilage.  The  term  is  commonly  apjilied  to  lesions  of  bone.  A  fi-acture 
may  be  partial  or  complete  ;  transverse,  oblique,  or  longitudinal ;  single, 
double,  or  multiple ;  simple,  comminuted,  compound,  and  complicated. 
A  partial  fracture  occurs  when  a  bone  breaks  or  splinters  on  one  side  (its 
convex  surface)  and  bends  on  the  opposite  (green-stick  fracture).  In  a 
complete  fracture  there  is  a  total  solution  of  continuity.  A  transverse 
fracture,  or  one  in  which  the  line  of  cleavage  is,  in  general,  at  a  right 
angle  with  the  axis  of  the  bone,  is  rare  as  compared  with  the  oblique.  A 
longitudinal  fracture  is  a  split  in  the  long  axis  of  a  bone.  Ir  is  frequently 
caused  by  penetrating  wounds  (gunshot),  or  may  result  from  a  fall  with 
great  violence  tipon  the  hands  or  feet,  when  the  cleavage  commences  in 
the  articular  surface.  In  this  way  the  astragalus  may  be  driven  between 
the  fragments  of  a  longitudinal  fracture  of  the  tibia,  or  a  like  accident 
occur  at  the  knee  or  wrist. 

A  single  fracture  is  one  break  in  one  bone  ;  a  double  fracture  is  a  so- 
lution of  normal  continuity  in  two  bones  of  one  member,  as  the  ulna  and 
radius,  the  tibia  and  fibula ;  multiple  fracture  is  a  term  applied  to  two 
or  moi'e  separate  breaks  in  one  or  several  bones.  When  a  bone  is  broken 
in  one  direction,  and  at  (me  point,  without  injury  of  any  surrounding 
organ  or  perforation  of  the  skin,  it  is  termed  a  simple  fracture  ;  if  there 
are  more  than  two  fragments  it  is  a  comminnfed  fracture  ;  if  any  part  of 
the  fractured  surface  communicates  with  the  atmosphere  it  is  a  com- 
pound; and  if  it  communicates  with  a  joint,  or  involves  in  the  fracture 
the  wound  of  any  important  organ,  as  a  large  artery  or  vein,  or,  as  in 
fracture  of  a  rib,  occasionally  the  pleura  or  lung  is  wounded,  it  is  a  com- 
plicafed  fracture.  An  imjjacted  fracture  is  one  in  which  the  fragments 
are  splintered  and  interlocked  with  more  or  less  complete  immobility. 

A  fracture  may  be  caused  by  external  violence,  directly  or  indirectly 
applied,  or  by  muscular  action,  or  both  factors  may  unite  in  the  produc- 
tion of  the  lesion.  As  an  example  of  direct  violence,  in  the  effort  to  ward 
f>ff  a  blow  from  the  head  the  ulna  may  be  broken  by  the  force  of  a  cane 
immediately  beneath  the  contusion  of  the  soft  parts.  A  blow  on  the 
vertex  which  fi-actures  the  base  of  the  skull,  or  a  fall  on  the  foot  which 
breaks  the  femur,  are  common  examples  of  fi-acture  from  indirect  vio- 
lence. Contraction  of  the  quadriceps  extensor  may  fracture  the  patella, 
or  the  same  lesion  may  result  from  a  fall  on  the  knee,  in  which  the  direct 
violence  and  the  action  of  this  powerful  muscle  unite  to  cause  the  fracture. 
In  addition  to  these  direct  agencies,  certain  conditions  of  the  tissues  pre- 
dispose to  fracture.  The  bones  of  the  aged  break  more  readily  and  are 
slower  in  repair  than  the  young  and  middle-aged.  There  is  a  not  infre- 
quent condition  of  fragility  in  the  bones  of  the  insane  which,  either  alone 


276  A   TEXT-BOOK  ON  SURGEllY. 

or  together  with  excessive  and  uiicontroUable  iuusciil;ir  jiction,  renders 
them  liable  to  break.  I  have  seen  one  specimen  of  this  nature  in  which 
every  ril)  was  broi'ven,  and  some  ol'  these  in  two  or  more  places.  As  hereto- 
fore stated,  fracture  is  common  in  the  disease  known  as  osteomalacia, 
and  may  occur,  though  less  likely,  in  rachitis.  Sex,  vocation,  and 
manual  preference  also  predispose  to  fracture.  Men  suffer  much  more 
frecjuently  than  women,  and  any  vocation  which  exposes  to  violence 
increases  the  proportion  of  fractures.  The  bones  of  the  right,  the  i)re- 
ferred  side,  are  more  frequently  broken  than  the  left. 

Symptoms'. — The  symptoms  of  fracture  are:  Loss  of  function  ;  ab- 
sence of  normal  contoKr  ;  preternatural  mot)Uity  ;  crepitus.  A  l)roken 
bone  which  is  not  impacted  no  longer  acts  as  a  support,  or  sustains  mus- 
cular contraction.  The  natural  shape  or  outline  is  more  or  less  distorted 
by  displacement  and  overlapping  of  the  fragments.  Caieful  niani))ula- 
tion  will  determine  the  overriding,  measurement  will  show  shortening, 
while  comparison  with  the  uninjured  side  will  detennine  the  degree  of 
asymmetry. 

Crepitus,  which  is  not  always  necessary  to  correct  diagnosis,  is  the 
sensation  imparted  to  the  touch,  and  occasionally  recognized  by  the  ear, 
when  the  rough  fragments  are  moved  so  as  to  grate  upon  each  other. 
The  diagnosis  of  an  impacted  fracture  is  more  difficult,  since  crepitus  and 
mobility  are  absent.  Shortening  must  of  necessity  exist,  which,  with 
partial  loss  of  function  and  more  or  less  pain  and  thickening  at  the  point 
of  fracture,  will  lead  to  the  recognition  of  the  lesion.  A  longitudinal 
fracture  or  fissure  is  often  with  difficulty  recognized,  and  may  escape 
detection. 

Process  of  Repair. — The  first  and  immediate  residt  of  a  fracture  is 
ha5morrhage,  which  occurs  from  the  arteries,  arterioles,  capillaries, 
venules,  and  veins  of  the  medulla,  compact  substance,  periosteum,  and 
any  surrounding  soft  parts  which  may  be  involved  in  the  injuiy.  As  a 
result  of  the  irritation  determined  by  the  accident  and  beemorrhage,  in- 
flammation is  precipitated.  Hyperspmia  of  the  bone  and  contiguous  soft 
tissues  ensues.  As  in  ostitis,  absorption  of  the  bony  walls  of  the  Haver- 
sian canals  occurs  with  the  dilatation  of  the  vessels,  and  general  cell-pro- 
liferation follows.  In  the  medullary  cavity  proper,  in  the  medullary 
spaces  of  the  Haversian  systems,  in  the  periosteum,  and  the  inflamed 
surrounding  tissues,  this  process  is  common.  As  in  all  inflammatory 
processes,  the  leucocytes  are  present  in  great  numbers.  The  medullo- 
cells,  myeloplaxes,  osteoblasts,  periosteal  cells,  and  connective-tissue 
corpuscles,  undergo  rapid  proliferation,  resulting  in  the  formation  of  a 
mass  of  common  embryonic  cells,  which  inflltrate  the  clot  between  and 
around  the  fragments.  New-forined  capillaries  are  pi'ojected  into  and 
through  this  graniilation-tissue  in  the  same  manner  as  in  the  process  of 
repair  in  wounds  of  the  soft  parts. 

If  the  broken  ends  do  not  come  in  contact  with  the  air — that  is,  if  the 
fracture  is  not  compound — the  jirocess  of  repair  in  bone  after  an  injury 
is  similar  to  the  physiological  process  of  development  of  this  tissue — 
namely,'  the  embryonic  tissue  is  develojjed  into  cartilage -cells,  and  these, 


FRACTURES.  277 

undergoing  proliferation,  develop  into  a  secondary  embryonic  tissue, 
which  is  formed  directly  into  bone.  If,  however,  air  is  admitted  to  a 
wound  in  bone,  the  process  of  ossification  in  the  embryonic  tissue  is  moi'e 
rapid  and  direct,  since  the  intermediate  stage  of  cartilage-cell  formation 
does  not  occur. 

A  portion  of  this  new-formed  tissue,  which  results  from  the  irritation 
following  a  fracture,  undeigoes  a  process  of  calcification  by  the  absorp- 
tion of  inorganic  material  from  the  blood,  and  is  then  known  as  calhis. 
That  portion  which  lies  around  and  on  the  outer  side  is  the  ensheafhinrf 
callus  ;  between  the  fragments,  the  intermediate  ;  and  within  the  medul- 
lary canal,  the  central  or  '•'•pin"  callus. 

In  an  adult  or  middle-aged  person,  commencing  within  the  first  few 
hours  succeeding  a  fracture,  the  embryonic  tissue,  which  is  formed  in 
varying  quantity,  remains  soft  and  yielding  until  about  the  tenth  day, 
when  the  cells  begin  to  be  infiltrated  with  calcareous  matter.  The  pro- 
cess of  solidification  in  the  callus  is  complete  at  a  period  varying  usually 
from  fifteen  to  thirty  days.  It  is  more  rapid  in  children,  and  slower 
in  the  old. 

"When  complete  displacement  with  ovei'lapping  occurs,  or  when  an 
aponeurosis  or  tendon,  or  other  dense  tissue,  sej^arates  the  broken  ends, 
the  process  of  callus-building  is  interfered  mth,  and  failure  of  ossification 
may  result. 

Usually  a  greater  portion  of  the  callus  becomes  absorbed  within  from 
thirty  to  sixty  days  after  the  fracture.  This  is  especially  true  of  the 
ensheathing  layer  and  the  central  callus.  That  portion  which  intervened 
between  the  opposing  surfaces  becomes  organized  into  pei'manent  bone. 
The  pin  callus  remains  for  a  while,  and  may  completely  occlude  the 
medullary  canal,  Init  usually  at  a  later  period  undergoes  absorption.  In 
some  cases  the  medullary  canal  is  not  re-establislied.  Fig.  307  shows  a 
section  of  a  broken  femur  in  which,  after  a  considerable  lapse  of  time,  the 
canal  was  still  occluded.  The  peculiar  stalactite  (exostosis)  occurred  at 
the  seat  of  fracture.  The  permanency  of  the  external  callus  and  its  de- 
velopment into  exostoses  depends  chieiiy  upon  the  disturbed  nutrition 
of  the  part  (Fig.  308).  It  has  been  noticed  that  when  a  fracture  occurs 
near  the  insertion  of  a  group  of  muscles  (as  at  or  near  the  trochanter), 
exostosis  is  the  rule,  and  may  be  very  extensive. 

Prognosis  and  Treatment  in  General. — The  prognosis  of  a  simple 
fractxire  in  a  healthy  child  or  adult  is  always  favorable.  The  danger  is 
increased  with  the  multiplicity  and  complications  of  the  accident.  A 
compound  fracture  is  siifficiently  grave  to  demand  the  greatest  attention. 
Death  may  result  from  sepsis  or  fatty  embolism.  A  longitudinal  fractui-e 
is  a  nu)re  serious  injury,  esjiecially  grave,  as  far  as  the  integrity  of  the 
member  is  concerned,  when  a  joint  is  implicated. 

In  all  forms  of  fracture  the  ]u-ogno'<is  increases  in  gravity  with  each 
decade  beyond  the  third.  When  the  fracture  is  complete,  and  displace- 
ment has  occurred,  exact  reposition  is  impossilile,  and  shortening  almost 
inevitable.  The  exceptions  are  extremely  rare,  especial!}'  in  the  single 
bones,  as  the  femur,  humerus,  and  clavicle. 


278 


A  TEXT-BOOK   ON   SURGERY. 


The  great  end  to  be  achieved  in  the  treatment  of  fractures  is  a  re- 
duction of  the  disi)lacenient  to  as  near  the  normal  as  j^ossible,  and  the 
absohite  retention  of  tlie  parts  as  replaced.     Reduction  may  usually  be 


Fio.  307. — Longitudinal  section  of  a  fractured  femur,  showing 
pcrmiiuent  occlusion  of  the  medullary  canal.  Tlic  stalactite 
u.M)st<«is  i.s  well  shown  in  the  right-band  figure.  (From  a 
sijcciuien  of  the  author's.) 


Flo.  308. — Permanent  thickenin};  from 
new-formed  bone  in  a  fractured  hu- 
merus. (From  a  specimen  of  the  au- 
thor's in  the  Wood  Museum.) 


accomplished  without  an  anaesthetic,  but  where  the  overlapping  is  con- 
siderable, and  muscular  contraction  and  rigidity  marked,  ether  narcosis 
should  be  secured.  The  comparative  safety  of  this  an;osthetic  justifies 
its  general  employment  in  fractures.  A  compound  fracture  demands, 
with  fixation,  free  drainage.  The  fragments  should  be  reduced,  even 
when  it  is  necessary  to  remove  projecting  ends  with  the  forceps  or  saw 
to  effect  this.  Once  placed  in  position,  they  should  be  kept  at  rest,  with 
openings  and  counter-openings. 

Special  Fractures — Cranium,. — The  bones  of  the  skull  may  be  fract- 
ured by  direct  or  indirect  violence.  Direct,  wlien  tlie  bones  give  way 
immediately  beneath  the  point  which  is  struck ;  indirect,  as  when,  by 
falling  from  a  height  and  striking  on  the  feet  or  buttocks,  the  base  of 
the  skull  is  fractured  by  the  force  transmitted  through  the  vertebral  col- 
umn. A  rarer  form  of  indirect  fracture  of  the  skull  is  that  known  as 
fracture  by  contre-coup^  in  which  the  bones  give  way  at  a  point  ojiposite 
to  that  at  which  the  injury  is  received. 

Fractures  of  the  skull  may  occur  with  or  without  compression  of  the 
brain  or  meninges.  The  outer  talile  may  be  dejiressed  by  crushing  into 
the  diploe  without  fracture  of  the  inner  or  viti'eous  table,  and,  strange  as 


FRACTURES. 


279 


it  may  appear,  in  raie  instances  the  inner  table  is  broken,  while  the  outer 
])late  is  not  depressed.  More  frequently  both  tables  are  involved. 
Fractures  of  the  skull  may  be  simi)]e,  compound,  comminuted,  compli- 
cated, single,  or  multiple.  They  are  chiefly  divisible  into  those  of  the 
tertex  and  those  of  the  base. 

Fractures  of  the  base  are  usu-  .-—    -  _, 

ally  due  to  indirect,  those  of  the 
vault  to  direct,  violence.  A  blow 
on  the  top  of  the  head  may  j^ro- 
duce  a  fracture  only  at  the  base,  or 
at  both  the  apex  and  base.  Usu- 
ally the  break  occurs  at  a  point  di- 
rectly in  the  line  of  the  force  which 
causes  the  lesion.  -Aran  demon- 
strated, by  dropping  cadavers  from 
a  height,  that  when  the  frontal  re- 
gion received  the  blow  the  fracture 
usually  took  place  in  the  anterior 
fossa,  the  middle  parietal  and  the 
occipital  region  giving  the  key  to  a 
fracture  respectively  in  the  middle 
and  i^osterior  fossse.  A  blow  on 
the  chin  has  been  known  to  pro- 
duce a  fracture  by  driving  the  in- 
ferior maxilla  against  the  temporal 
bone.  A  fall  on  the  buttocks  may 
produce  a  comminuted  fracture,  the 
force  being  transmitted  through  the 

vertebral  column.  Fig.  309  is  a  copy  from  a  specimen  I  placed  in  the 
Wood  Museum  of  Bellevue  Hospital.  The  patient,  a  heavy  man,  a  sail- 
01-,  fell  through  the  hatchway  to  the  hold  of  the  ship,  a  distance  of  about 
twenty  feet,  striking  on  tlie  buttocks.  Death  occurred  instantly.  The 
head  was  not  bruised.  The  cause  of  death  was  a  comminuted  fracture, 
extending  througli  the  temporal,  occipital,  and  sphenoid  bones. 

Diagnosis. — The  diagnosis  of  fracture  of  the  vertex  may  be  i-eadily 
determined  when  an  open  wound  exists.  In  many  instances  a  depression 
may  be  determined  by  palpation,  even  when  the  scalji  is  unbroken. 
Symptoms  of  compression  of  the  brain  are  not  reliable  aids  in  the  diag- 
nosis of  fracture  in  the  first  few  days  after  an  injury,  for  the  reason  that 
any  violence  sufficient  to  ])roduce  a  fracture  is  also  likely  to  produce 
sjTuptoms  of  concussicm  which  might  easily  be  mistaken  for  compres- 
sion. The  escape  of  brain-substance  or  the  ventricular  fluids  is  of 
course  an  unmistakable  sign.  At  the  base,  one  of  the  most  reliable 
symptoms  of  fracture,  yet  not  always  a  positive  indication  of  this  lesion, 
is  luemorrhage,  or  the  escape  of  a  serous  fluid  from  the  ears.  This  only 
oc(;urs,  however,  when  the  line  of  fracture  passes  through  the  petrous 
portion  of  the  temporal  bone.  Swelling  of  the  vault  of  the  pharynx  is 
not  without  siguilicance  v.hen  any  violence  has  l)eeu  sulYered  which  leads 


If  JO -J. 


Fig.  309. — Comrcinuted  fracture  at  the  base  of  the 
skull,  from  a  fall  on  the  buttocks,  i  From  a  speci- 
men  of  the  author's  in  the  Wood  Museum.) 


280  A  TEXT-BOOK   OX   SUIUiERY. 

to  the  sTispicion  of  riiictme  of  tlic  skull.  If  the  luisiliir  ])rocess  of  the 
occipital  bone  is  involved,  extravasation  will  not  unlikely  be  present  in 
this  region.  Loss  of  vision  or  the  sense  of  smell  indicate  lesion  '<)t  the 
anterior  fo.ssa.  In  many  instances  the  diagnosis  must  rest  wholly  ui)on 
subjective  symptoms. 

liased  upon  no  objective  symptoms,  the  dilTcrentintion  between  co/i- 
cuss/'o//  and  compression,  of  the  brain  is  dilficult,  and  often  inii)ossii)le. 

In  general,  it  may  be  said  that  the  symptoms  of  roinpresslon  ;ire  those 
of  pjiralysis,  usually  unilateral  and  more  profound  tjiiui  the  sytuptonis  of 
concussion. 

In  simple  concussion  the  patient  may  be  aroused  to  partial  conscious- 
ness, the  respiratory  movements  of  the  muscles  of  the  fnce  will  be  sym- 
metrical, equality  of  t!ie  pupils  is  maintained,  and  vomiting  is  of  frequent 
occurrence.  In  compression,  stupor  is  apt  to  be  prolonged  and  pro- 
found, the  facial  muscles  are  drawTi  to  one  side,  and  the  buccinator  of  the 
aft'ectetl  side  is  apt  to  puff  out  with  the  exj^iratory  elfort.  There  may  be 
inequality  of  the  pupils,  and  vomiting  is  absent. 

In  the  treatment  of  concussicm  of  the  lirain  the  first  indication  is  rest. 
The  recumbent  posture,  with  the  head  elevated,  should  l)e  maintained. 
If  there  is  marked  coldness  of  the  skin,  and  evidence  of  great  prostraticm 
or  impending  colkqise,  wnrnith  should  be  applied  locally,  and  stimulants 
hypodermically.  StimTdants  must,  however,  be  given  with  discretion, 
since  the  fever  of  reaction  may  be  increased  by  their  excessive  use. 
After  the  shock  passes  off,  cold  applications  to  the  head  are  essential. 

Th'^  treatment  of  fractures  at  the  base  is  altogether  expectant.  Sur- 
gical interference  is  raiely  if  ever  called  for.  In  fractures  of  the  vault, 
witli  tlepression,  in  adults,  the  trephine"  should  be  applied  as  soon  after 
the  injui-y  as  is  consistent  with  the  patient's  safety.  If  shock  is  pi'esent 
without  serious  compression,  it  will  be  wise  to  wait  until  I'eaction  is  es- 
tablislied.  When,  however,  dangerous  depression  exists,  immediate  op- 
eration, even  without  an  an;esthetic,  is  demanded.  When  the  symptoms 
of  depression  are  not  prominent,  an  exploratory  incision  is  justifiable  in 
order  to  determine  with  certainty  whether  there  is  comjn-ession  of  tlie 
brain  or  meninges.  With  antiseptic  precautions  this  operation  adds 
little  to  the  gravity  of  the  patient's  condition. 

A  comminuted  fracture  in  an  adult  always  demands  the  elevation  and 
removal  of  the  fragments.  A  linear  fracture,  with  depression,  even  if  this 
is  thought  to  be  confined  to  the  outer  plate,  also  demands  the  trephine  as 
far  as  the  diploe,  and,  if  the  depression  involves  the  inner  table,  this 
should  also  be  raised  and  the  fragments  removed.  A  fracture  made  by  a 
narrow  instrument,  or  other  jjenetrating  substance,  as  a  gunshot  missile, 
etc.,  demands  the  tre]:)hine  at  the  point  of  entrance.  In  children,  the  tol- 
eration of  the  brain  to  pressure  is  such  as'to  justify  delay  in  elevation  of 
the  fragments  unless  alarming  symptoms  supervene. 

Localized  paralysis,  coming  on  immediately  after  an  injurj^  to  the 
skull,  calls  for  trephining  at  once.  It  is  always  better  to  operate  early 
than  to  defer  interference  until  inflanmiatory  symptoms  are  present. 
The  danger  is  enhanced  by  such  delay.     The  disrepute  which  this  opera- 


FRACTURES. 


281 


fcion  has  fallen  into  has  been  chiefly  due  to  too  great  procrastination  in 
surgical  interference. ' 

Operation. — Besides  the  ordinary  cutting  and  lijemostatic  apparatus, 
a  trejihine  and  elevator  will  be  found  necessary,  while  a  rongeur  and 
sequestrum-forceps  will  be  of  great  service.  Of  the  various  trephines, 
the  conical  instrument  of  Gait  is  preferable  (Fig.  80). 

The  scalp,  within  two  or  three  inches  of  the  wound,  should  be  shaved 
perfectly  clean,  and  it,  together  with  rhe  hair,  washed  with  l-to-3000 
sublimate  solution.  In  cutting  down  to  the  lione,  any  wound  which  may 
exist  should  be  utilized,  and  may  be  enlarged  by  a  crucial  incision,  if 
found  necessary.  The  bleeding  is  arrested  by  catgut  ligatures.  The 
periosteum  sliould  not  be  lifted. 

When  the  fracture  is  well  exposed,  if  there  is  gi'eat  comminution,  and 
if  the  fragments  are  not  tightly  impacted,  they  may  be  lifted  by  the 
elevator  without  trephining.  If  this  instrument  is  required,  advance  the 
central  bit  about  one  eighth  of  an  inch  beyond  the  level  of  the  circular 
teeth,  and  fasten  it  flrmly  here  by  turning  the  screw  near  the  center  of 
the  shaft.  The  point  of  the  bit  should  be  applied  upon  the  solid  iinfract- 
ured  bone,  aliout  one  fourth  of  an  inch  from  the  fissure,  and  the  greater 
part  of  the  button  lifted  from  the  uninjured  bone.  The  instrument  is 
now  caused  repeatedly  to  rotate  for  a  half  circle  and  back,  and  sufficient 
jiressure  is  made  to  carry  the  point  and  teeth  into  the  calvarium.  "When 
the  teeth  have  cut  a  circle  about  one  sixteenth  of  an  inch  in  depth  the 
instrument  should  be  removed, 
and  the  bit  slipped  up  the  shaft 
to  its  original  i^osition.  As  the 
operation  proceeds,  the  trephine 
should  be  removed  every  few 
turns  and  the  ring  cleaned  oiit 
with  a  tooth -pick.  A  slight 
bleeding  is  apt  to  occur  when 
the  diploe  is  entered.  As  soon 
as  the  inner  table  is  divided  the 
instrument  becomes  locked  and 
practically  immovable.  Wound- 
ing the  dura  mater  is  scai'cely 
probable  if  the  trephine  is  held 
perj^endicular  to  the  plane  of  the 
bone  which  is  being  cut.  If  the 
button  does  not  come  up  with 
the  instrument,  it  should  be  lift- 
ed out  with  the  elevator  or  for- 
ceps. The  elevator  may  now  be  carried  carefully  under  the  edge  of  the 
de]iressed  bone,  and,  using  the  solid  surface  for  a  fulcrum,  lifted  into 
position,  or,  if  comminuted,  removed.  It  is  always  important  to  look 
for  any  fragments,  however  small,  which  are  apt  to  lie  broken  off  from 
the  vitreous  table  and  driven  l)t'tw(>en  the  dtira  mater  and  the  skull.  Ii 
the  dura  be  torn,  the  bleeding  should  be  arrested  by  catgut  ligatures, 


'k' 


\ 


Flo.  310. — FruL'ments  removed  by  the  tropliino  ami  ele- 
vator in  n  depressed  fracture  eausL-d  by  a  bbiw  with 
a  baminer.  The  bcvelinij  at  tlie  expeiisic  ut"  the  vit- 
reous tiible  is  wull  sliowu. 


282  A  TEXT-BOOK   ON   tSURGERY. 

and  the  wound  in  this  membrane  closed  by  sutures  of  the  same  material 
(Fig.  310). 

The  wound  should  be  treated  under  strict  antisepsis,  and  sliDuld  be 
kept  open  with  a  light  dressing  of  iodoformized  and  sublimate  gauze 

The  trephine  should  not  be  applied  over  the  track  of  the  longitudinal 
or  lateral  sinuses  and  the  middle  meningeal  artery.  l)epress(Hl  bone  may 
be  lifted  from  these  vessels.  Hjcmorrhage,  if  it  occur,  may  be  controlled 
by  the  ligature  or  by  compression. 

JVasal  Bones. — One  or  both  nasal  bones  may  be  fractured  and  de- 
pressed, and  in  severe  injuries  the  nasal  processes  of  the  superior  maxilla 
and  the  perpendicular  plate  of  the  ethmoid  are  involved. 

Hfcmorrhage  from  within  the  nose  is  usually  severe,  and  may  require 
the  tami)on  of  the  anterior  and  posterior  nares.  The  reposition  of  the 
fragments  should  be  effected  with  great  care.  A  strong,  blunt,  and  nar- 
row instrument  passed  along  the  septum  nasi  until  it  is  in  contact  with 
the  inner  surface  of  the  fragments,  together  with  lateral  pi-essure  fiom 
without  and  at  the  base  of  the  nose,  will  best  reduce  the  disj)laced  pieces*. 
In  order  to  hold  the  fragments  m  position,  the  method  of  treatment  in- 
troduced by  Dr.  Le\Ais  D.  Mason  will  be  found  preferable.  After  reposi- 
tion, as  alK)ve  described,  a  steel  drill  (a  straight  surgical  needle  will  suf- 
fice) is  passed  directly  across  the  nose,  being  entered  through  the  line  of 
fracture.  Over  the  ends,  which  project  through  the  integument  on  either 
side  of  the  nose,  a  strip  of  pure  rubber  "is  jjlaced,  across  the  bridge  of 
the  nose,  by  puncturing  either  end  on  the  head  and  point  of  the  needle, 
giving  the  rubber  sufficient  tension  to  exert  a  gentle  downward  and  lat- 
eral compression,  but  not  enough  to  interfere  with  the  circulation  or  to 
exert  a  degree  of  pressure  on  the  fragments.  The  point  and  head  of  the 
needle  may  be  i:)rotected  by  small  pieces  of  cork."*  The  needle  may  be 
removed  about  the  sixth  to  the  tenth  day.  When  the  blow  is  received 
on  the  side  of  the  nose,  the  fracture  and  depression  may  be  unilateral. 
In  such  cases,  replacement  effected  after  the  manner  just  described  will 
usually  suffice,  since  the  fragments  are  not  likely  to  be  displaced  when 
once  in  position. 

At  times,  and  esitecially  in  children,  wlien  the  nasal  arch  is  struck 
from  the  front,  the  fracture  occurs  at  the  naso-maxillary  suture,  and  the 
nasal  bones  are  driven  in  without  comminution.  In  this  variety  of  de- 
pression considerable  force  is  needed  to  effect  reduction.  Such  is  the 
rapidity  with  which  repair  and  union  occur  here,  as  in  all  the  bones  of 
the  face,  that,  if  the  effort  at  reduction  is  delayed  for  more  than  twenty- 
four  or  forty-eight  hours,  it  will  be  exceedingly  difficult,  if  not  impos- 
sible, to  accomplish. 

Fracture  of  the  malar  hone  occurs  rarely,  and  is  the  result  of  violence 
so  great  that  usually  the  upper  jaw  and  other  bones  are  broken.  Every 
effort  should  be  made  to  restore  the  normal  contour  to  the  face  by  repo- 
sition of  the  fragments,  none  of  which  should  be  removed,  since  the 
vitality  of  the  bones  of  the  face  is  so  great  that  necrosis  after  injury  is 
exceptional. 

*  "Annals  of  Anatomy  and  Surgery,"  vol.  ii,  pp.  110  and  199. 


FRACTURES.  283 

AVlien  the  fracture  is  compound,  and  this  is  usually  the  case,  the 
fraf;:ments  may  be  lifted  into  place  through  the  wound,  by  means  of  the 
l)ul]et-scre\v  elevator,  or  other  instruments  ;  or,  as  advised  l)y  Hamilton, 
the  linger  or  thuml)  inay  be  passed  underneath  the  lip  to  the  zygomatic 
arch,  which  can  be  utilized  as  a  point  for  pressure.  At  times,  however, 
it  may  be  necessary  to  enter  the  antnini  riiaxiUare  by  trephining  or  drill- 
ing through  the  anterior  wall  of  the  antrum.  The  jioint  of  enti'ance 
should  be  immediately  above  the  first  (or  anterior  molar)  tooth,  at  a  dis- 
tance of  from  one  half  to  three  fourths  of  an  inch  below  the  inferior  mar- 
gin of  the  orbit. 

Fracture  of  the  zygomatic  process,  either  of  the  malar  or  temporal 
bones,  may  occur  singly  or  as  a  complication  of  the  fracture  just  treated. 
If  the  force  which  j)roduces  the  lesion  does  not  wound  the  temporal  or 
maxillary  arteries,  the  treatment  is  simple.  If  the  depression  is  sufficient 
to  cause  deformity,  cut  down  to  the  arch,  insert  a  hook  elevator,  and  lift 
the  bone  into  i^lace.  It  may  be  necessary  to  limit  mastication  by  the  ap- 
plication of  a  bandage,  as  in  fracture  of  the  lower  jaw. 

The  siqjen'o/-  maxilla  may  alone  be  broken,  although  it  is  usually 
complicated  with  fracture  of  other  bones.  A  blow  received  at  the  roots 
of  the  teeth  may  drive  the  alveolar  and  palatal  arch  downward,  or,  if  the 
direction  of  the  impinging  body  is  from  before  backward  and  upward, 
the  antrum  may  be  ojiened. 

The  treatment  is  to  cleanse  the  wound  antiseptically  and  replace  all 
pieces  of  bone  as  well  as  possible. 

The  following  case  illustrates  in  a  remarkable  degree  the  vitality  and 
reparative  ]iower  in  the  bones  of  the  face :  In  September,  1884,  a  robust 
Irishman,  about  forty  years  of  age,  came  into  my  service  at  Mount  Sinai 
Hospital.  He  had  just  been  kicked  by  an  unshod  horse.  The  crescentic 
wound  extended  from  the  center  of  the  forehead  down  by  the  nasal  pro- 
cess, along  the  facial  groove,  and  out  beyond  and  below  the  malar  bone. 
The  soft  tissues  were  lacerated,  and  the  bones  extensively  comminuted. 
Tlie  wound  was  cleansed  of  particles  of  manure,  straw,  and  pieces  of 
hoof.  Strict  antisepsis  was  employed,  thoroughly  cleansing  the  wound 
and  replacing  every  piece  of  bone.  Tke  torn  edges  were  pared  and  closed 
by  silk  sutures.  Rapid  union  ensued,  without  the  exfoliation  of  any 
portion  of  the  bone. 

The  great  desideratum  is  the  prevention  of  a  scar.  Upon  the  face  the 
greatest  care  must  be  taken  to  avoid  deformity.  If  the  soft  tissues  are 
torn  and  contused,  the  edges  of  the  wound  should  be  smoothly  pared  and 
nicely  approximated  by  tine  silk  sutures. 

When  the  destruction  of  the  bone  is  so  extensive  that,  even  after  re- 
l)osition  of  the  pieces,  the  fragments  will  not  remain  in  jilace.  it  may  be 
necessary  to  use  the  lower  jaw  as  a  splint,  bj^  fixation  of  the  two  rows 
of  teeth,  with  the  head  and  chin  figure-of-8  dressing,  as  for  fracture  of 
tlie  lower  jaw.  The  interposition  between  the  teeth  of  short  strips  of 
gutta-percha,  thoroughly  softened  in  warm  water,  will  firmly  fix  the 
l)roken  to  the  unbrokt>n  Ixmes,  and  admit  of  the  introduction  of  liquid 
food  between  the  upper  and  lower  incisors. 


284  A  TEXT-BOOK   ON   SURGERY. 

Frat'ture  of  the  iiifcrlnr  maxilla  niny  ocoiu-  in  rare  instances  through 
the  symphysis  mentis  but  much  more  frecjuently  external  to  this  and  near 
the  o]ienin,<i-  of  the  mental  foiaiiicn.  Tlie  majority  of  all  fractures  are  of 
the  body,  autl  within  the  hi'st  inch  and  a  hali  leadini^  baclvward  fi-om  the 
symphysis. 

Fracture  of  the  anf/lc  or  raiinis  is  iufiequent,  and  is  usually  the  result 
of  a  blow  upon  the  side  of  the  jaw.  The  corojwid  process  is  rarely  if 
ever  broken,  except  by  penetrating  bodies.  The  condyle  may  be  broken 
through  its  neck  by  a  fall  or  blow  on  the  chin,  or  ))y  force  applied  later- 
ally at  or  near  the  angle. 

Diagnosis. — Among  the  symptoms  of  this  lesion  are  pain  at  the  point 
of  fracture  and  loss  of  function.  If  tlie  break  is  comi)lete,  the  diagnosis 
is  made  evident  in  the  displacement  which  usually  occurs,  and  by  the 
jiresence  of  crepitus.  This  bone  may,  however,  be  broken  without  dis- 
placement, and  where  crepitus  is  not  present.  Under  su(^h  ct)nditions, 
while  a  diagnosis  may  not  be  positive  until  the  swelling  which  indicates 
the  formation  of  callus  ensues,  the  jaw  should  be  kejit  at  rest  by  one  of 
the  methods  to  be  described.  When  the  fracture  occurs  at  or  posterior 
to  the  mental  foramen,  the  temporary  loss  of  function  of  the  inferior 
dental  nerve,  which  is  not  infrequent,  points  almost  unerringly  to  a 
recognition  of  tlie  character  of  the  lesion.  When  the  neck  of  the  condyle 
is  broken,  the  chief  sym]itoni  is  ])ain  in  this  region,  with  jiartial  or  com- 
plete loss  of  function.  Crepitus  is  with  difhculty  elicited  by  the  surgeon, 
althougli  it  may  be  evident  to  the  patient. 

Treatment  and  Prognosis. — Immediate  reposition  of  the  broken  and 
displaced  surfaces,  and  as  perfect  a  degree  of  rest  as  possible,  are  the 
first  and  chief  indications  for  treatment.  When  the  presence  of  a  par- 
tially displaced  tooth  offers  an  obstacle  to  close  adaptation  it  should  be 
removed.  When  reduction  is  effected,  one  among  the  following  methods 
may  be  employed : 

A  simple  and  ready  method,  which  may  be  used  until  a  more  secure 
apparatus  is  constructed,  is  found  in  the  four-tailed  bandage  (Fig.  32). 
The  fragments  being  carefully  adjusted,  the  bandage  is  applied  as  already 
given  on  page  20.  The  figure-of-8  chin  and  head  bandage  (Fig.  24)  is 
also  an  excellent  emergency  dressing  for  fracture  of  the  lower  jaw.  If 
this  is  intended  to  be  used  permanently,  a  leather  or  gutta-percha  cup 
should  be  constructed,  to  tit  over  the  chin  and  well  along  the  body  of  the 
jaw.  The  material  should  be  cut  from  three  to  three  and  a  half  inches 
wide  and  about  six  to  seven  inches  in  length,  and  si:)lit  from  each,  end  in 
its  long  axis  to  within  three  fourths  of  an  inch  of  the  center.  One  strip 
should  be  about  half  an  inch  narrower  than  the  other.  If  gutta-percha 
is  used,  this  should  be  dipj>ed  in  warm  water  for  a  minute  or  two,  until 
it  becomes  softened.  It  is  then  laid  across  the  chin,  the  upper  and  nar- 
row ends  are  turned  back  over  and  parallel  with  the  body  of  the  jaw, 
while  the  lower  ends  are  turned  upward  an<l  made  to  cross  ovitside  the 
horizontal  ends.  The  bandage  is  api)lied  over  this  cup,  which  soon 
hardens  into  an  unyielding  dressing.  Leather  may  be  prepared  in  the 
same  way,  but  requires  to  be  soaked  longer  than  the  rubber.    Inter-dental 


FRACTURES. 


285 


splints,  made  of  gutta-percha  strips,  cut  aljout  one  inch  and  a  half  in 
length,  from  one  fourth  to  one  half  of  an  inch  in  width,  and  about  one 
fourth  of  an  inch  in  thickness,  are  sometimes  employed  to  fix  the  molar 
teeth  immovably,  and  at  the  same  time  to  separate  the  anterior  teeth 
enough  to  allow  of  the  introduction  of  liquid  fo(jd.  These  strips  should 
also  be  softened,  and,  when  placed  between  the  teeth,  the  crowns  of  the 
molars  are  pressed  into  the  rubber  by  the  dressing.  AVhen  the  fracture 
is  through  the  molar  region,  the  strip  on  the  broken  side  is  placed  on 
either  side  of  the  fracture. 

The  most  suitable  apparatus  is  that  of  Prof.  Hamilton,  seen  iu  Fig. 
311.  It  consists  of  a  chin-and-head  strap,  made  of  strong,  soft  leather. 
This  piece,  where  it  passes  under  the  chin, 
is  shaped  so  that  while  it  maj'  not  cause 
uncomfortable  pressure  at  the  base  of  the 
tongue,  it  is  wide  enough,  as  it  passes  up 
on  to  the  side  of  the  face,  to  include  the 
angle  of  the  jaw  in  its  support.  From  this 
point  it  is  gradually  narrowed,  until  at  the 
temple  it  is  an  iuch  in  width,  and  the  same 
where  it  is  buckled  at  the  fronto-parietal 
suture.  A  piece  of  cloth,  fashioned  so  as 
to  fit  like  a  cup  over  the  chin,  is  sewed  on 
to  this.  A  second  strij)  is  buckled  around 
the  head,  across  the  forehead  and  beneath 
the  occiput,  and  from  this  point  an  antero- 
posterior strap  iiasses  forward  to  the  max- 
illary piece,  to  which  it  is  attached  at  the 
fronto-parietal  Junction.     By  shortening  or 

elongating  this  straj:)  the  direction  of  the  pressure  on  the  Jaw  can  be 
changed,  while  it  prevents  the  maxillary  stiip  from  pulling  forward.  A 
piece  of  soft  lint  or  cotton  should  be  placed  under  each  buckle.  If,  after 
the  apparatus  is  applied,  the  teeth  fit  so  closely  together  that  it  is  impos- 
sible to  introduce  liquid  nourishment,  inter-dental  splints  of  gutta-percha 
should  be  employed. 

A  patient  with  a  fractured  Jaw  should  not  be  allowed  to  talk,  and, 
when  in  bed,  should  be  required  to  rest  in  the  dorsal  decubitus,  so  as  not 
to  press  laterally  ujion  the  injured  bone. 

The  ^j/'rt;//;o.s/s  is  usually  favorable.  Fixation  by  ossification  occurs 
in  from  two  to  five  weeks.  In  some  cases  later,  while  in  a  small  number, 
in  which  ])roiier  treatment  has  been  delayed,  or  the  character  of  the  in- 
jury severe,  or  the  condition  of  repair  in  the  patient  unfavoral)le,  uniim 
is  delayed  or  fails  utterly.  In  instances  of  delayed  union  fixation  should 
be  faithfully  tried.  If  this  fails,  and  the  function  of  the  Jaw  is  seriously 
impaired,  the  point  of  fracture  should  be  exposed  by  incision,  the  broken 
edges  scraped,  <me  or  two  holes  drilled  through  each  fragment,  one  foui'th 
of  an  inch  from  the  edges,  and  fixation  secured  by  means  of  silver  wires. 

Fracture  of  the  cartihigcs  of  the  larynx  is  of  rare  occurrence.  Sim- 
ple fracture  heals  without  retentive  apparatu.s,  quiet  being  the  chief  indi- 


FiG.  311.— (.Vfter  Hamilton.) 


286 


A  TEXT-BOOK   ON   SURGERY. 


cation.  The  prognosis  is  grave  in  pi-opoition  to  the  danger  of  asphyxia 
from  inflammatory  swelling  or  emphysema.  When  the  force  has  been 
great,  and  tlie  comminution  extensive,  deatli  may  occur  fi'om  shock  or 
other  complication  before  aspliyxia  from  occlusion  of  the  trachea  super- 
venes. AVhen  this  last  danger  is  threatened,  tracheotomy  should  be  per- 
formed early. 

AVhen  the  os  hyoides  is  broken,  the  fragment,  if  displaced  or  driven 
through  the  soft  tissues,  may  be  brought  into  position  by  introducing 
one  finger  into  the  month  and  pressing  with  the  other  hand  from  witli- 
out.  It  is  scai'cely  possible  to  retain  the  ends  in  apposition,  and  librous 
union  is  apt  to  occur.  The  accident  is  rare,  is  not  dangerous,  and  the 
prognosis  consequently  favorable. 

Clainde. — The  clavicle  is,  next  to  the  radius,  more  frequently  the  seat 
of  fracture  than  any  other  bone.  In  children  the  fracture  is  rarely  com- 
plete, and  consequently  overlapping  is  not  met  with,  as  is  the  rule  in 
adults.  The  break  occurs,  in  a  large  majority  of  instances,  in  the  middle 
third,  i.  e.,  in  that  porticm  of  the  bone  between  the  attachments  of  the 
trapezius  and  sterno-mastoid  muscles.  This  frac'ture  may  be  caused  by 
direct  violence,  or  by  indirect  force,  as  a  fall  upon  the  shoulder  or  the 
extended  arm. 

The  character  of  the  displacement  is  shown  in  Fig.  312.  The  inner 
fragment  is  held  in  position  by  the  mastoideus  muscle,  and  is  prevented 
from  being  carried  upward  by  the  costoclavicular  ligament.     The  weight 

of  the  arm  and  shoulder  drags  the  outer 
fragment  downward,  while  the  contractit)ns 
of  the  pectoralis  major,  latissimus  dorsi, 
and  subclavius  muscles  carry  it  toward 
the  middle  line  of  the  body,  beneath  the 
inner  fragment.  In  rare  instances  the  dis- 
placement is  the  reverse. 

The  diagnosis  rests  upon  loss  of  func- 
tion, pain  at  the  seat  of  lesion,  possiblj' 
crepitus,  loss  of  symmetry,  shortening, 
and  recognition  of  displacement  by  pal- 
pation. 

The  prognosis  is  good  as  to  restoration 
of  function,  although,  in  complete  fract- 
ure, overlapping  and  a  certain  amount  of 
permanent  deformity  and  shortening  are 
almost  inevitalde. 

Treatment. — In  comi:)lete  fracture  over- 
lapping of  the  fragments  may  be  correct- 
ed, and  the  ends  brought  into  apjiosition, 
by  first   carrying   the  arm  and   shoidder 
backward,  and  then  elevating  the  shoulder.     This  is  the  princijjle  in- 
volved in  Prof.  Sayre's  excellent  method  of  treating  this  lesion,  w'hich  is 
as  follows : 

Cut  two  strips  of  strong  adhesive  plaster  (moleskin  is  preferable) 


Fio.  312.— (From  Gray.t 


FRACTURES. 


287 


about  three  inches  wide  and  several  feet  in  length.  Just  above  the  el- 
bow of  the  arm  on  the  injured  side,  one  strij),  witli  the  adhesive  surface 
nearest  the  body,  is  passed  around  the  arm  and  secured  with  a  safety-pin, 
so  that  it  will  not  constrict  the  member  (Fig.  313).     The  hand  is  now  laid 


1^^ 

Fig.  313.— The  first  strip. 


Fig.  314. — Sayre's  dressinw  for  fractured  clavicle. 
Front  view. 


over  the  middle  of  the  sternum,  the  shoulder  elevated,  and  the  elbow 
carried  well  backward  by  an  assistant,  while  the  operator  carries  the 
plaster  directly  around  the  body  by  the  back,  fastening  it  snugly  to  the 
integument.  The  second  strip  is  split  near  its  middle  for  about  three 
inches,  for  the  accommodation  of  the 
elbow,  and  is  applied  along  the  fore- 
arm and  over  the  shoulder  of  the 
sound  side,  and  obliquely  around  the 
back  to  the  same  i)oint  (Figs.  314, 
315).  A  wad  of  absorbent  cotton 
should  be  placed  in  the  axilla  of  the 
aifected  side,  and  between  the  hand 
and  the  sternum.  The  plasters  should 
be  stitched  or  fastened  securely  with 
safety-pins. 

A  convenient  and  effective  ready- 
method  is  that  of  Prof.  Moore,  of 
Rochester.  A  strip  of  sheeting,  eight 
inches  in  width  and  three  vards  long, 
is  held  near  its  center  across  the  palm 
of  the  operator,  who,  for  the  left 
clavicle,  grasps  the  elbow  of  this  side 
from  behind;  That  end  of  the  strip  which  is  next  the  patient's  body  is 
passed  between  the  arm  and  chest,  then  up  in  front  of  and  over  the  clav- 
icle of  the  injured  side,  obliquely  across  the  back,  under  the  opjiosite 
axilla,  thence  across  the  right  clavicle,  and  over  this  to  the  back. 


Fio.  315. — Sayre's  second  strip  for  fractured 
clavicle.     Buck  view. 


288 


A  TEXT-BOOK   OX   SURGERY. 


The  opposite  end  is  passed  to  the  fidiit  of  tlu'  iirm  at  the  elbow,  be- 
tween tile  iirst  strij)  and  the  arm,  and  is  then  carried  around  the  back. 
An  assistant  now  carries  the  elbow  backward  and  upward,  and,  wliile 
held  in  this  position,  the  bandage  is  tied,  sewed,  or  pinned.  A  sling  to 
support  the  forearm  is  added.  This  is  practically  a  ligure-of-8  band- 
age around  the  elbow  of  the  broken  side  and  the  shoulder  of  the  sound 


Fio.  316. — Moore's  method. 


Fio.  317. — Moore's  method. 


side.  The  hand  is  carried  across  the  chest,  slightly  elevated,  and  is 
held  in  a  sling.  Safety -jDins  are  inserted  at  the  points  of  crossing  (Figs. 
316,  317). 

In  incomplete  fracture,  and  in  children,  especially  during  the  summer 
months,  when  the  plaster  tends  to  produce  imtation  of  the  skin,  Vel- 
peau's  method  is  preferable.     (See  page  321.) 

Any  form  of  ajiparatus  should  be  worn  at  least  four  weeks. 

The  scapnla  is  almost  always  broken  by  direct  violence.  It  is 
thought  to  have  been  fractured  in  a  few  instances  by  muscular  action 
alone. 

Acromiou  Process. — The  acromion  'process  is  usually  broken  by  a 
fall  on  the  shoulder  or  a  blow  received  from  al)ove.  Tlie  fracture  may 
occur  anterior  to,  through,  or  behind  the  acromio-davicular  articulation. 
The  diagnosis  is  evident  from  crepitus,  preternatural  mobility,  and  de- 
pression of  the  outer  end  of  the  clavicle.  The  treatment  is  to  bend  the 
forearm  at  a  right  angle  to  the  arm,  and  throw  a  roller  under  the  forearm, 
at  the  elbow,  and  over  the  clavicle  and  shoulder  of  the  affected  side,  fix- 
ing the  head  of  the  humerus  in  the  ui)per  part  of  the  shoulder-joint  and 
lifting  the  acromion  into  its  i^lace. 

Coracoid  Process. — When  this  process  is  broken  the  tendency  to  dis- 
placement is  downward,  owing  to  the  action  of  the  pectoralis  minor, 
coraco  brachialis,  and  short  head  of  the  bicejjs.     Unless  the  fracture  is 


FRACTURES.  289 

anterior  to  the  attachments  of  the  coraco-clavicular  ligaments,  or  unless 
these  have  been  detached,  the  displacement  can  only  be  limited. 

Treatment. — Place  the  hand  of  the  injured  side  on  the  opposite  shoul- 
der, and  apply  Velpeau's  bandage  as  for  fracture  of  the  clavicle.  The 
prognosis  is  good,  although  fibrous  union  is  the  rule. 

Fracture  of  the  glenoid  process — that  is,  through  that  portion  of  the 
scapula  l)etween  the  glenoid  fossa  and  the  anterior  portion  of  the  base  of 
the  coracoid  process — has  not  yet  been  noted.  Several  instances  are  re- 
corded, however,  of  fracture  which,  while  anterior  to  the  base  of  the 
acromion,  included  the  base  of  the  coracoid  process. 

Treatment. — Flex  the  forearm  at  right  angles  to  the  arm,  and  carry  it 
across  the  chest,  leaving  the  humerus  parallel  with  the  axis  of  the  body. 
Lift  the  humerus  directly  upward  against  the  coraco-acromial  ligament, 
place  a  pad  in  the  axilla,  and  carry  a  roller  around  and  under  the  fore- 
arm, at  the  elbow,  and  over  the  shoiilder  of  the  same  side.  Fjvery  other 
turn  should  be  carried  horizontally  around  the  body.  By  this  means  the 
liead  of  the  humerus  keejjs  the  fragment  in  position. 

Fracture  of  the  spine  of  the  scapula  is  rare,  but  below  this  it  is  of 
more  frequent  occurrence.  Velpeau's  bandage,  or  any  method  which 
will  give  the  minimum  of  discomfort  and  the  greatest  degree  of  rest,  will 
be  most  successful. 

Humerus. — Fracture  of  the  Itiimerus  occurs  most  frequently  in  its 
lower  tliird,  while  the  proportion  of  fractures  in  the  middle  and  upper 
thirds  is  about  equal. 

In  the  upper  third  this  bone  may  be  bi'oken  through  the  anatomical 
neck;  just  below  this  line,  through  the  tuberosities;  inmiediately  below 
the  tuberosities  (the  surgical  neck) ;  or  through  the  shaft.  It  may  also  be 
fractured  longitudinally,  with  seimration  of  the  tuberosities. 

Fracture  of  the  anatumical  necl\  or  intra-capsular  fracture,  is  rare. 
It  is  caused  by  a  blow  or  fall  directly  on  the  shoulder. 

Diagnosis. — There  may  be  crepitus.  If  the  shoulder  is  fixed  and  the 
humerus  grasped  below  and  up  to  the  tuberosities,  and  crepitus  is  felt  by 
moving  the  head  against  the  glenoid  cavity,  the  character  of  the  injury 
is  evident.  If  impaction  into  the  shaft  lias  occurred,  crepitus  will  be 
absent,  but  shortening  will  be  ascertained  by  careful  measurement. 

Bony  union  after  intra-capsular  fracture  is  rare,  unless  impaction  has 
occurred.  Osteo-arthritis  may  result,  rendering  exsection  of  the  joint 
necessary. 

Fracture  througJi  the  tuberosities  occurs  also  from  direct  violence. 
The  symptoms  closely  resemble  those  of  the  variety  just  described.  The 
prognosis  is  more  favorable,  since  bony  union  is  the  rule.  Prognosis  as 
to  freedom  of  motion  should  be  guarded,  since  exostosis  may  result  to 
such  an  extent  as  to  interfere  with  the  usefidness  of  the  arm. 

Fracture  through  the  surgical  neck  is  of  far  more  frequent  occurrence 
than  the  intra-  or  extra-capsuhir  fractures  at  tlie  anatomical  neck.  It 
may  result  from  direct  violence,  although  not  infrequently  a  fall  upon 
the  hand  or  elbow  will  produce  it.  The  bases  of  the  tuberosities  are 
rarely  involved  in  fracture  of  the  neck  in  adults — except  in  the  young, 

]9 


290 


A  THXT-BOOK  ON  SURGERY. 


Fio.  318. — Sliowinz  tlie  mechan- 
ism of  displaiit'rnent  in  fract- 
ure iif  the  surgical  neck  of 
the  humerus.    (AtlcrGray.) 


when  separation  at  the  epiphysis  may  occur.     In  the  midrlle-aged  and 

old  the  point  of  fracture  is  usually  about  one  inch  below  the  tuberosities. 

Displacement  may  occur  in  any  direction,  althouuh  as  a  rule  it  is  not 

extreme.     The  tendency  of  the  lower  fiaunient  is  to  be  drawn  u])ward  by 

the  deltoid  and  triceps,  inward  liy  the  pectoralis 
major  and  latissimus  dorsi,  and  ui)ward  and  in- 
ward by  the  short  head  of  the  biceps  and  the 
coraco-brachialis  (Fig.  318). 

Loiif/itiKliiial  Fracture. — This  form  of  fract- 
ure, though  I'are,  occurs  from  direct  injury.  The 
split  usually  runs  through  the  head  of  the  hu- 
merus and  along  the  bicijjital  groove,  resulting 
in  a  separation  of  the  greater  tid)erosity  from  the 
shaft.  The  bone  will  be  found  to  be  flattened 
and  wider  than  normal,  while  a  deep  groove 
marks  the  line  of  cleavage.  The  prognosis  is 
unfavorable  as  to  restoration  of  function. 

Differential  Diagnosis. — In  dislocation  of 
the  shotdder-joint  tliere  is  always  abnoi'mal  im- 
mobility ;  the  muscles  of  the  shoulder  and  arm 
are  rigid  ;  a  measurement  over  the  acromion  and 
around  through  the  axilla  will  be  at  least  one 
inch  greater  than  on  the  non-dislocated  side  ;  the  head  of  the  bone  will  be 
felt  out  of  its  normal  position  ;  if  the  hand  of  the  affected  side  is  laid  upon 
the  opposite  shoulder,  the  elbow  can  not  be  made  to  touch  the  chest- wall. 
In  fracture  without  ini])action,  creintus  and  shortening  ;  nu»re  or  less 
pain  on  motion ;  mobility  free ;  the  circumference  not  increased ;  the 
head  of  the  bone  in  position  ;  with  the  hand  of  the  affected  side  upon 
the  opposite  shoulder  the  elbow  drops  to  the  chest.  AVith  impaction,  all 
of  these  symptoms  except  crepitus. 

Treatment. — Reduction  of  displacement  is  usually  effected  by  exten- 
sion from  the  flexed  forearm,  the  shoulder  l)eing  fixed  by  traction  in  the 
opposite  ai"m,  or  by  a  sheet  carried  around  the  body,  just  under  the 
axilla.  In  the  first  mano'uvre  it  is  iisually  best  to  hold  the  arm  at  right 
angles  to  the  body,  and,  continuing  the  extension,  to  bring  it  down  par- 
allel with  the  chest,  in  which  position  it  is  to  be  fixed.  To  this  is  added 
direct  manipulation  of  the  fragments.  The  choice  of  dressings  may  be 
made  between  plaster  of  Paris  and  a  cup-shaped  splint  of  gutta-percha, 
sole-leather,  or  book-binder's  board.  Properly  adjusted,  either  of  these 
materials  will  suffice.  The  gypsum  dressing  has  the  advantage  of  more 
certain  and  permanent  fixation  of  the  parts.  It  is.  however,  not  so  com- 
fortable as  the  shoulder-cap  splint.  To  apjdy  the  plaster-of-Paris  sjilint, 
reduce  the  displacement  as  directed,  and  fix  the  arm  in  a  position  not 
quite  parallel  with  the  body,  by  firm  and  regular  extension.  Apply  a 
dry  muslin  or  flannel  roller  to  the  arm  and  shoulder,  as  heretofore  de- 
scribed, and  over  this  put  on  the  plaster-of-Paris  bandages,  holding  the 
arm  perfectly  immovable  until  the  gypsum  has  hardened. 

If  a  shoulder-cap  is  to  be  applied,  a  pattern  is  first  made  by  cutting 


FRACTl^.ES. 


291 


a  piece  of  paper  to  fit  over  the  shoulder  and  down  the  arm.  It  should 
be  large  enough  to  spread  over  a  part  of  the  scapular  and  pectoral  region, 
and  to  embrace  two  thirds  of  the  circumference  of  the  ami.  The  paste- 
board, gutta-percha,  or  leather  is  cut  to  coiTespond  to  this,  and  is  im- 
mersed in  hot  water  until  it  is  soft  and  pliable,  when  it  is  lined  with  a 
thin  layer  of  absorbent  cotton  and  molded  over  the  arm  and  shoulder, 
where  it  is  secured  by  a  roller,  applied  as  above.  The  inner  side  of  the 
arm  is  protected  by  cotton  or  cloth.  The  forearm  and  hand  should  be 
bandaged,  and  held  in  front  of  the  ensiform  cartilage  by  means  of  a  sling. 
If  the  dressing  becomes  loose,  an  additional  roller  should  be  applied. 
Any  dressing  for  this  fi-acture  should  be  worn  continuously  for  at  least 
four  weeks.  In  order  to  prevent  contraction  of  the  biceps,  it  will  be  ad- 
visable to  fully  extend  the  forearm  every  two  or  three  days. 

Fractures  of  the  shaft  of  the  humerus,  although  chietly  caused  by  di- 
rect violence,  are  not  infrequentl  j'  the  result  of  a  fall  on  the  hand  or  elbow, 
and  may,  in  rare  instances,  be  caused  by  muscular  action  alone.  The  dis- 
placement, which  is  usually  not  marked,  will  in  great  part  be  determined 
by  the  dii-ection  of  the  line  of  fi-acture.  If  the  break  is  above  the  inser- 
tion of  the  deltoid,  while  the  lower  fragment  is  di'awn  upward  by  the  del- 
toid and  the  long  muscles  extending  from  the  scapiila  to  the  elbow,  the 
upper  fragment  is  apt  to  be  drawn  toward  the  thorax  by  the  pectoralis 
major  and  minor  and  latissimus  dorsi  muscles  (Fig.  318).  If  the  break 
is  below  the  deltoid  tubercle,  the  dis- 
placement and  overlapping  will,  in  gen- 
eral, follow  the  obliquity  of  the  fract- 
ure. The  lower  fragment  is  ajjt  to  be 
drawn  behind  the  upper  longer  piece. 

The  treatment  is  practically  the  same 
as  that  just  given.  If  the  cup-shaped 
splint  is  used  it  should  be  made  long- 
er, and  an  extra  short,  narrow,  internal 
splint  may  be  added  (Fig.  319).  The 
plaster-of-Paris  dressing  is  very  satis- 
factory in  this  region  of  the  arm. 

Fracture  at  the  condyloid  extremity 
of  the  humerus  may  be  divided  into  : 
1,  transverse  fracture  above  the  con- 
dyles, caused  by  violence  applied  to 
the  elbow  ;  2,  epiphyseal  separation  (on 
a  plane  lower  than  the  above) ;  3,  trans- 
verse fracture,  with  a  longitudinal  sjjlit 
into  the  joint  (inter-condyloid)  ;  4,  fract- 
ure of  the  external  condyle ;  5,  of  the  in- 
ternal condyle;  6,  of  the  external  epicondyle  ;  7,  the  internal  epicnndyle. 

In  transverse  fracture  al)ove  the  condyles  the  obliquity  is  usually 
from  behind  forward  and  downward  (Fig.  32U),  the  inferior  short  frag- 
ment being  carried  up  behind  the  hmger.  When  the  lower  fragment  is 
split  into  the  joint,  the  displacement  is  the  same. 


Fio.  319. — Apparatus  lor  tiacture  of  the  hu- 
merus at  any  point  above  tlie  condyles. 
1^ After  Hamilton.) 


292 


A  TEXT-BOOK   ON   SURGERY. 


Kio.  320. — Showini;  mechanism  of  diR- 
placement  in  fracture  above  the 
condyles.     (After  Gray.) 


In  epiphyseal  separation  the  displacement  is  not  great,  unless  the 
capsule  is  badly  torn,  as  a  result  of  extreme  violence. 

The  treatment  of   these   throe   forms  of 
.IV-  ,»    ,  .  .  ,.-      fracture  is  the  same.     Ileduction  by  exten- 
sion  and  the  long   L-shaped   cup-splint  of 
y  Hamilton    should    be   preferred   (Fig.    319). 

This  splint  is  made  of  gutta-percha  (leather 
or  g()(Kl  caid-board  will  suffice  if  the  rubber 
can  not  be  obtained).  It  should  go  from  the 
shoulder  to  the  wrist,  and  the  measurements 
should  be  taken  on  the  nnl)roken  anu.  The 
apparatus  should  be  padded  with  a  layer  of 
absorbent  cotton.  Instead  of  holding  the 
forearm  at  a  right  angle  to  the  arm,  as  repre- 
sented in  the  cut,  it  is  best  to  carry  it  about 
half  way  between  this  position  and  fidl  ex- 
tension, in  order  to  carry  the  olecranon  pro- 
cess into  the  fos.sa,  which,  if  allowed  to  fill 
■with  callus,  will  prevent  full  ext«msif)n  of  the 
foreann.  The  prognosis  is  more  favorable  in 
the  first  variety,  since  the  joint  may  not  be 
involved  in  the  injury.  Destruction  of  the  joint,  requiring  excision,  may 
occur  in  epiphyseal  sejiaration.  When  the  fracture  is  comminuted,  and 
into  the  joint,  anchylosis,  more  or  less  complete,  may  result. 

In  all  fractures  about  the  elbow  it  is  important  to  remove  the  splints 
at  the  end  of  the  third  week,  steady  the  fragments  above  and  below  the 
line  of  fracture  as  well  as  possible,  and  make  limited  motion  at  the  elbow- 
joint.  The  splints  are  again  adjusted,  and  at  the  end  of  another  week 
this  manoeuvre  is  repeated,  with  an  increased  degree  of  motion.  After 
this,  every  two  or  three  days,  until  the  greatest  possible  freedom  of  move- 
ment is  secured. 

The  internal  conch/le  is  broken  much  more  frequently  than  the  exter- 
nal. It  is  more  prominent,  and,  in  the  act  of  falling  backward,  the  arms 
are  thrown  out  from  the  body  in  such  a  manner  that  the  inner  condyle 
first  receives  the  force  of  the  fall.  Tlie  fracture  may  be  confined  to  the 
tip  (extra-capsular),  or  it  may  include  a  portion  of  the  internal  epicon- 
dyle,  and  lead  into  the  joint  through  the  trochlear  surface. 

Fracture  of  the  external  condyle  is  of  I'are  occurrence.  The  line  of 
cleavage  usually  commences  about  the  middle  of  the  external  condyloid 
ridge,  and  runs  obliquely  to  the  articular  surface,  in  the  groove  between 
the  radial  eminence  and  the  trochlear  surface,  or  through  the  center  of 
this  surface.  The  diagnosis  is  determined  by  the  crepitus,  degree  of 
mobility  of  the  fragment,  and  by  the  partial  loss  of  function  of  the  ex- 
tensor or  flexor  muscles  (as  the  outer  or  internal  condyle  is  affected). 

Treatment. — In  fracture  of  the  inner  condyle,  whether  complete  or 
incomplete,  flex  the  forearm  on  the  arm  to  an  angle  slightly  less  than  45°, 
and  pronate  the  foreann  until  the  back  of  the  hand  is  uppermost.  This 
position  most  fully  relaxes  the  flexors  and  the  pronotor  radii  teres.     Use 


FRACTURES. 


293 


the  same  splint  as  just  described.  It  is  advisable  to  place  a  compress  of 
cotton  or  liut  in  front  of  the  condyle,  in  order  to  increase  the  pressure 
backward. 

For  the  external  condyle,  bend  the  forearm  as  before,  and  place  the 
hand-palm  upward.  In  all  these  lesions  plaster-of-Paris  or  liquid-glass 
dressings  may  be  used,  although  a  well-made  and  well-applied  gutta- 
percha, shellac,  leather,  or  pasteboard  shoulder,  arm,  and  forearm  splint 
is  preferable. 

Separation  of  the  epicondyles  is  of  rare  occurrence,  and  demands  no 
especial  mention.  The  indications  for  treatment  are  similar,  and  the 
prognosis  more  favorable  than  for  fracture  of  the  condyles. 

Forearm — Ulna. — Fracture  of  the  olecranon  process  usually  occurs 
as  a  result  of  a  fall  on  the  elbow, 
when  the  forearm  is  in  strong  flex- 
ion. It  is  occasionally  caused  by 
contraction  of  the  triceps.  The  line 
of  fracture  is  most  frequently  at  the 
epiphyseal  junction.  The  displace- 
ment is  upward,  in  the  line  of  the 
triceps  (Fig.  321). 

The  diagnosis  may  be  determined 
by  loss  of  function,  crepitus,  which 
may  be  obtained  when  the  forearm 
is  fully  extended,  or  by  appreciation 
of  the  sej^aration  of  the  two  frag- 
ments. 

Treatment. — Extend  the  foreai-m 
to  the  fullest  degree  consistent  vdtXi 
comfort.  Make  a  soft-board  splint, 
two  or  three  inches  wide,  and  long 
enough  to  extend  from  within  two 
inches  of  the  carpus  to  the  same  dis- 
tance from  the  axilla.  Cut  a  deep 
notch  on  either  side,  three  inches  below  the  level  of  the  line  of  fiacture. 
Pad  the  splint  with  batting,  making  it  twice  as  thick  in  the  bend  of  the 

elbow    as    elsewhere, 
and  wrap   it  with   a 
roller.    Lay  the  splint 
on   the  anterior  sur- 
face of   the  ann  and 
forearm,  and  secure  it 
near  the  ends  by  sev- 
eral turns  of  the  roll- 
er.   Xext,  take  a  flan- 
nel bandage  (on   ac- 
count of  its  elasticity),  and,  commencing  below,  cover  the  forearm  and 
splint  by  circular  turns  until  the  notch  is  reached,  at  which  moment  the 
roller  is  carried  well  above  the  upper  fragment,  ai'ound  the  posterior 


Fig.  321. — Displacement  of  the  upper  fragment  in 
fracture  of  the  olecranon.     (Alter  Gray.) 


Fig.  322. — Hamilton's  olecranon  splint. 
Hamilton.) 


( After 


Fig.  323. — Hamilton's  drcs-iius  for  fracture  of  the 
(.\tter  Hamilton.; 


olecranon. 


294 


A   TEXT-BOOK    ON   SIJRGKRY. 


aspect  of  the  arm.  and  down  again,  to  bo  secured  in  the  notcli  on  the 
opposite  side  of  the  sj)llnt.  This  obliqun  turn  is  rejteated  until  tht^  fiag- 
nients  are  in  ajjposition,  when  tlie  whole  is  secured  by  as  many  circidar 
turns  as  are  needed  (Fig.  ;323).  Within  a  week  the  ^fractnre  should  be 
inspected,  by  removing  a  portion  of  tlu?  dressing,  and  ailditi<mal  tui'iis 
api)lied  if  any  separation  has  occunvd.  After  four  or  Jive  weeks  the 
splint  should  be  removed,  and  careful  i)assive  motion  made,  while  the 
fragments  are  supported  by  the  operator.  The  union  is  apt  to  be  liga- 
mentous. 

Fracture  of  the  coronoid  process  is  exceedingly  rare.  The  diagnosis 
is  difficult — often  impossible.  If  the  lesion  is  strongly  suspected,  secure 
quiet  by  ai)i)]ying  a  splint  in  extreme  flexion. 

Fracture  of  the  ulna,  in  its  shaft,  occurs  in  the  effort  to  ward  off  a 
blow,  or  as  a  result  of  a  fall  dii-ectly  upon  the  bona. 

The  diagnosis  is  usually  not  difficult,  even  when  displacement  is  slight. 
In  suspected  fracture  of  one  of  the  bones  of  the  forearm,  if  {■()mi)rt'ssiou 
be  made  by  grasping  both  bones  at  a  point  remote  from  the  suspected 
break,  an<l  ]>ain  or  abnoi'mal  mobility  be  caused  at  tliat  point,  tlie  diag- 
nosis of  fracture  is  fairly  clear.  If  crepitus  is  obtained,  all  doubt  is  dissi- 
pated. 

Displacement  of  the  ujiper  fragment  is  always  slight.  The  lower  may 
be  drawn  toward  the  radius  by  the  pronator  quadratus.  The  obliquity 
of  the  cleavage,  and  the  direction  of  the  force  which  produced  the  lesion, 
wOl  almost  always  determine  the  displacement. 

Radius. — Fracture  of  the  radius  above  the  bicipital  tuberosity  is  one 
of  the  rarest  forms  of  injury,  and,  when  present,  is  with  great  difficulty 
recognized.  The  cause  is  direct  violence.  Displacement  of  the  upper 
fragment  will  be  slight,  unless  the  fracture  is  comi)li(,'ated  with  a  disloca- 
tion at  the  radio-humeral  joint.  The  action  of  the  biceps  will  tend  to 
draw  the  lower  fragment  forward.  The  best  position  for  treatment  is  to 
flex  the  forearm  on  the  ami,  with  the  palm  turned  upward,  and  to  apply 
an  anterior  splint,  wider  than  the  arm,  and  provided  with  an  interosseous 

pad.  If  the  displacement  forwai-d 
is  extreme,  a  compress  may  be  em- 
ployed. 

Fracture  of  the  radius  between 
the  bicipital  tuberosity  and  the  in- 
sertion of  the  pronator  radii  teres 
is  also  usually  from  a  direct  blow, 
although  it  may  result  from  a  fall 
071  the  hand,  or  from  muscular  ac- 
tion.*   While  the  obliquity  of  the 
line  of  fracture  will  in  great  part 
determine  the  displacement,  the  tendency  is  for  the  lower  fragment  to 
be  carried  toward  the  ulna  by  the  conjoined  action  of  the  pronator 
quadratus  and  pronator  radii  teres  muscles,  while  the  upper  fragment  is 


Fio.  324.— Disi>laccment  of  the  frngments  in  fr.icture 
of  tlie  radius  in  its  lower  third.     (Alter  Gray.) 


*  Packard,  iu  Aslihurst's  "  Encyclopajdia," 


William  Wood  &  Co.,  New  York. 


FRACTURES. 


295 


rotated  oxitward  by  the  biceps.  When  the  bone  is  broken  below  this 
point  the  lower  fragment  tends  toward  the  ulna.  The  upjier  may  be 
held  out  by  the  biceps,  or  carried  toward  the  ulna  if  the  pr<jnator  radii 
teres  is  contracted  ('Fig.  324). 

Treatment. — The  po.sition  which  renders  the  approximation  of  the 
fragments  most  easy  is  that  of  supination  ;  but  in  this  position  the  two 
bones  are  almost  in  apposition,  and  the  danger  of  osseous  union  between 
them,  with  loss  of  lateral  motion,  is  increased.  For  this  reason  it  is  safer 
to  fix  the  limli  half  way  between  supination  and  pronation  (with  the 
thumb  pointing  upward).  (The  application  of  the  splint  is  the  same  as 
for  fracture  of  both  bones. ) 

Fracture  at  the  Carpal  End  of  the  Radius. — Fracture  through  the 
cancellous  expansion  of  the  lower  end  of  the  radius  is  the  most  frequent 
of  all  fractures  ;  that  of  the  clavicle  next  in  order.  The  line  of  fracture 
is  in  general  transverse,  and  within  one  inch  of  the  articular  surface, 
being  usually  nearer  the  anterior  margin  of  the  articular  surface,  and 
running  obliquely  upward,  on  to  the  dorsal  aspect  of  the  bone,  at  a  dis- 
tance varying  from  one  fourth  to  one  inch  above  the  posterior  lip.  In 
very  exceptional  instances  the  posterior  lip  or  rim  is  sjjlit  off,  the  line  of 
fracture  leading  from  the  articular  surface  upward,  on  to  the  dorsal 
aspect  of  the  bone  (Barton's  fracture).  The  styloid  process  is  also  occa- 
sionally broken  off,  or,  when  the  violence  of  the  fall  is  great,  the  bone 
may  be  split  in  its  long  axis  by  the  first  impact  of  the  carpus,  and  after- 
ward transversely  fractured  by  the  forced  extension  and  strain  on  the 
anterior  ligaments. 

Though  a  fall  on  the  back  of  the  hand  has  been  known  to  produce  a 
transverse  fracture  of  the  cant^ellous  expansion  of  the  carpal  end  of  the 
radius  in  a  few  instances,  in  the  vast  majority  of  cases  the  force  is  first 
received  upon  the  palmar  aspects  of  the  fingei's  and  the  palm,  with  the 
hand  in  forced  extension. 

The  mechanism  of  this  lesion  is  this :  In  the  act  of  falling,  the  hand 
is  thrown  out,  and  the  ftare  of  the  fall  is  received  first  upon  the  palm, 
and  chiefly  upon  the  anterior  extremity  of  the  metacarpus,  whence  it  is 
transmitted  backward  to  the  carpus,  and  to  the  anterior  radio-carpal 


Fio.  325.— Displacement  of  fragments  in  CoUcs's  fracture.     (Aller  Gray.) 

ligaments.  As  the  extension  is  continued,  the  strain  on  this  ligament  is 
increased,  until  the  bone  begins  to  yield  on  its  anterioi-  asjx'ct.  close  to 
and  parallel  with  the  radial  attaclnnent  of  the  ligament,  and,  us  the  force 


296  A  TEXT-BOOK   ON  SURGERY. 

is  continued,  tlie  line  of  fracture  travels  up\viu<l  and  l);ickward.  The 
same  force  which  produced  the  fracture  by  forced  extension  iind  inipiict 
of  the  body  will,  if  continned,  |)rodnce  the  usnid  disiiliiccnicnt,  causiug 
tlie  lower  fragment  to  I'ide  backward  upon  tlic  iipi)cr,  and  fieipiently 
causing  impaction  of  the  compact  posterior  rim  of  tlie  ujiper,  into  the 
spongy  snl)stance  of  tile  lower  fragment  (Fig.  ;!2.")). 

The  diacjuosls  of  (Jolles's  fracture  is  not  dillicuU.  Tlie  "  silver-fork" 
deformity,  the  history  of  the  accident,  and  pain  at  the  seat  of  the  lesion, 
point  to  the  character  of  the  fracture.  When  backward  dis])lacement 
occurs  it  will  be  recognized  by  palpation.  Crepitus  may  or  may  not  be 
elicited.  The  hand  is  directed  to  the  radial  side,  and  the  styloid  process 
of  the  ulna  is  unusually  ]ir(uninent. 

Treatment. — When,  after  careful  examination,  there  is  found  any 
degree  of  displacement  of  the  lower  fragment,  upward  and  bac^kwai'd 
iipon  the  upper,  proceed  as  follows  :  With  the  back  of  the  patient's  hand 
turned  upward,  the  operator  with  one  hand  grasps  the  forearm  in  such  a 
way  that,  while  the  radius  is  firmly  held,  the  thumb  is  immediately  above 
the  line  of  fracture.  With  the  other,  the  hand  of  the  patient  is  grasped 
so  that  his  (the  surgeon's)  thumb  (or  index-finger,  if  preferred)  presses 
firmly  upon  the  back  of  the  lower  fragment.  The  hand  is  now  carried 
strongly  back  toward  the  dorsal  aspect  of  the  radius  (forced  and  extreme 
extension),  and  while  in  this  position  the  lower  fragment  becomes  un- 
locked, and  may  be  pushed  into  place  by  the  thumb,  while  at  the  same 
time  the  hand,  under  strong  extension,  is  carried  into  the  straight  position. 
If  this  manoeuvre  fails  it  should  be  repeated,  and  under  ether  if  there  is 
great  pain  or  muscular  resistance.  Too  much  stress  can  not  be  laid  ujjon 
this.  The  cause  of  so  much  deformity  after  this  accident  is  in  many  cases 
due  to  imperfect  reposition.  If  no  displacement  exists,  extension  or  the 
employment  of  any  force  is  contra-indicated.  Injections  of  2-per-cent 
cocaine  solution,  after  Coming's  method,  into  the  tissues  about  the  line 
of  fracture  will  usually  produce  a  sufficient  anaesthesia.  In  aged  patients, 
who  have  considerable  imjiaction,  it  is  not  advisable  to  break  up  the  im- 
paction, but  deformity  and  impaired  usefulness  should  be  prognosti- 
cated. In  cases  with  little  or  no  displacement  and  deformity  all  exten- 
sion or  manipulation  should  be  abstained  from. 

In  many  instances,  however,  deformity  will  inevitably  remain.  The 
shortening  which  may  result  from  the  accident,  or,  in  the  young,  the 
injury  to  the  epiphysis,  which  may  retard  the  growth  of  the  bone  in  its 
long  axis,  causes  a  deflection  of  the  hand  to  the  radial  side,  and  an  ab- 
normal projection  of  the  styloid  process  of  the  ulna.  When,  as  in  some 
exceptional  instances,  the  radio-ulnar  ligaments  are  torn,  and,  as  de- 
scribed by  Prof.  Moore,  of  Rochester,  the  tendon  of  the  extensor  carpi 
ulnaris  is  displaced,  the  tendency  to  deformity  is  even  greater.  When 
proper  reduction  is  obtained,  any  dressing  which  keeps  the  parts  at  rest 
will  secure  a,  good  result. 

Within  the  last  few  years  a  large  number  of  cases  of  Colles's  fracture 
have  been  treated  with  Prof.  Pilcher's  dressing,  slightly  modified.  The 
results  have  been  vei-y  satisfactory.    It  is  as  follows  :  Roll  two  pieces  of  a 


FRACTURES. 


297 


bandage,  two  inches  and  a  half  wide,  into  a  compress  about  as  thick  as  the 
little  finger.  After  the  reduction,  place  one  along  the  inner  aspect  of  the 
ulna,  extending  from  the  anterior  margin  of  the  carpus  upward,  the  other 
exactly  parallel  with  this,  along  the  outer  border  of  the  radius,  over  its 
styloid  process.  While  these  are  held  firmly  in  position,  secure  them  by 
strips  of  adhesive  jjlaster,  one  inch  in  width,  wound  securely  around  the 
wrist  and  arm,  from  the  lower  end  of  the  carpus  to  the  end  of  the  com- 


FiG.  320. — Plastcr-of-Paris  dressing  for  CoUcs's  fracture. 

presses.  A  pasteboard  splint  is  then  applied,  along  to  the  back  of  the 
hand,  extending  from  the  bases  of  the  fingers  to  near  the  elbow.  The 
hand  and  arm  are  carried  in  a  sling.  The  dressing  may  be  changed  in 
two  or  three  weeks.  Gentle  and  careful  motion  of  the  fingers  should  be 
made  daily.     The  dressing  should  be  worn  about  four  weeks. 

Another  method  is  to  envelop  the  forearm  and  hand,  as  far  as  the 
metacarpo- phalangeal  articulation,  in  a 
plaster-of-Paris  dressing.  In  this  treat- 
ment, after  reposition  of  the  fragments, 
the  hand  should  be  given  a  considerable 
declination  to  the  ulnar  side.  If  it  is 
desired  to  examine  the  condition  of  the 
fracture,  the  plaster  may  be  cut  on  the 
iilnar  and  radial  sides,  and  reapplied  as 
a  modified  Bavarian  splint  (Fig.  326). 

Prof.  Hamilton's  method  is  as  fol- 
lows :  A  wooden  splint,  made  from  a 
box-top  or  shingle,  is  shaped  to  extend 
from  a  half  inch  in  front  of  the  elbow- 
joint  to  the  nietacarpo-phalangeal  artic- 
ulation. Its  breadth  is  equal  to  that  of 
the  arm  at  its  widest  part.  This  splint 
is  thrust  into  a  muslin  sack  (the  seam 
of  which  is  kept  away  from  the  arm), 
and  is  stufPed  moderately  full  of  cotton, 
wool,  or  hair.  The  packing  should  be 
a  little  thicker  in  the  hollow  of  the  palm  and  just  abo^^e  the  lower  end  of 
the  upper  fragment.  A  straight  dorsal  splint  mhy  also  be  employed.  It 
is  stuffed  in  the  same  manner  as  the  other,  leaving  the  packing  a  little 


Fill.  327.— (After  Hamilton.) 


298  A  TEXT-BOOK  ON  SURGERY. 

thicker  just  over  the  caritiis.  After  the  fragments  are  reduced,  the  splints 
are  applied,  and  held  in  place  by  bandages,  as  shown  in  Fig.  327. 

Fnictiire  of  the  styloid  jirocess,  and  longitudinal  fracture,  should  be 
treated  by  the  moditied  IMlcher  dressing. 

In  fractures  of  both  bones  of  the  forearm  proceed  as  follows  :  Pre- 
])are  two  s))lints  of  thin  board,  one,  the  ixtsterior,  to  extend  from  with- 
in one  incli  of  the  olecranon  to  the  ends  of  the  fingers  ;  the  anterior  to 
extend  from  the  elbow  to  the  carpus ;  both  wMer  than  the  forearm  at 
every  point.  Pad  these  with  some  soft  material,  considerably  thicker  in 
the  center  than  elsewhere,  to  serve  as  an  interosseous  pad.  Wrap  each 
splint  with  a  bandage  to  hold  the  padding  in  place.  An  assistant  grasps 
the  patient's  hand  and  arm  above  the  elbow,  and,  with  the  forearm  at  a 
right  angle  to  the  humerus,  held  in  a  position  half  way  ])etween  supina- 
tion and  pronation,  makes  steady  extension,  while  the  operator  makes  a 
careful  reposition  of  the  fragments.  Apply  the  splints  so  that  the  inter- 
osseous pads  will  push  the  muscles  down  and  between  the  radius  and 
ulna.  Then  fasten  them  by  a  bandage  made  tight  enough  to  prevent 
slipping.  If,  in  the  course  of  a  few  days,  the  dressing  becomes  loosened, 
it  can  be  tightened  by  applying  an  additional  roller.  The  forearm  is 
carried  in  a  sling.  The  treatment  should  be  continued  for  about  four 
weeks,  when  passive  motion  at  the  elbow,  and  supination  and  pronaticm, 
shoiild  be  made,  and  the  dressing  i-eadjusted  for  another  week.  This 
simple  dressing  is  sufficient  for  all  fractures  of  one  or  both  bones  of  the 
forearm  (excepting  Colles's  or  Barton's). 

ConijMiund  fractures  of  the  bones  of  the  forearm  require  fixation  by 
tliis  method,  and  the  security  of  open  wounds,  free  drainage,  and  strict 
antisepsis. 

Carpus — Metacarpus — Phalanges. — Fractures  of  the  carpus  occur 
from  great  and  direct  violence,  being  almost  invariably  compound.  The 
treatment  should  be  fixation,  rest,  and  drainage  under  antiseptic  precau- 
tions. 

The  metacarpal  bones  may  be  broken  by  direct  violence  or  by  blows 
or  falls  on  their  distal  ends.  This  fracture  is  not  uncommon  with  boxers. 
I  had  under  observation  three  brothers,  professional  pugilists,  each  of 
whom  had  a  metacarpal  fracture,  and  one  of  whom  had  also  a  fracture  of 
the  radius,  all  received  while  sparring.  In  the  young,  in  rare  instances, 
separation  may  occur  at  the  epiphyses,  which  are  at  the  phalangeal  ex- 
tremities of  the  metacarpal  bones  of  the  fingers,  and  at  the  carpal  ex- 
tremity for  that  of  the  thumb.  The  fracture  of  a  metacarpal  bone, 
broken  by  indirect  violence,  is  usually  situated  in  its  middle.  The  acci- 
dent is  recognized  by  i)ain,  displacement,  or  crepitus.  The  treatment  is 
reduction  by  extension  and  counter-extension,  with  direct  manipulation 
and  the  application  of  an  anterior  splint,  padded  and  arched  so  as  to  fill 
the  concavity  of  the  palmar  aspect  of  the  bone,  and  to  extend  to  the 
end  of  the  linger.  A  posterior  splint  is  also  api)lied,  lioth  fastened  by  a 
roller.  The  danger  is  from  fixation  of  the  extensor  tendon  as  a  result 
of  inflammation.  Passive  motion  of  the  finger  every  day  will  prevent 
this  result. 


FRACTURES.  299 

Fractures  of  the  PTialanges. — In  the  treatment  of  fractures  of  these 
bones  the  same  principles  are  involved  as  for  the  metacarpus.  The  chief 
precaution  is  to  prevent  stiffening  of  the  finger  from  adliesion  of  the 
tendons  to  their  sheaths.  Passive  motion  should  be  made  as  early  as  the 
sixth  day. 

The  Sferniivi — Ribs — Vertebra. — The  sternum  may  be  broken  by 
direct  or  indirect  violence.  In  recent  cases  reposition  may  be  effected  by 
pressure,  or  by  lifting  with  an  elevator.  In  the  treatment  of  these  cases 
the  most  i^erfect  quiet  should  be  enforced.  Necrosis  occasionally  follows 
this  accident,  necessitating  operative  interference. 

Fracture  of  the  ribs  or  of  their  cartilages  may  result  from  (1)  indirect 
violence,  as  a  blow  upon  the  sternum  ;  (2)  from  a  direct  injury  ;  or  (3) 
from  muscular  contraction. 

The  longer  ribs  are  most  liable  to  fracture.  When  the  force  is  applied 
to  the  sternum,  the  break  most  frequently  occurs  at  or  Just  anterior  to  the 
middle  of  the  bone. 

The  displacement  is  usually  slight.  Hsemorrhage  from  division  of  the 
intercostal  vessels  is  one  of  the  immediate  dangers,  while  localized  intlam- 
niation  of  the  parietal  pleuiti  is  inevitable.  The  diagnosis  will  depend 
upon  i^ain,  elicited  by  pressure  on  the  bone,  at  a  point  remote  fi"om  the 
fractiire,  and  occasionally  by  a  peculiar  click  or  crepitus  felt  by  the  hand 
applied  over  the  lesion  during  a  full  respiratory  act.  The  respiratory 
movement  is  less  free  ujjon  the  affected  side. 

Treatment. — Fixation  of  the  chest-wall,  as  far  as  is  possible,  is  the 
indication  in  treatment.  To  this  end,  the  affected  side  should  be  shaved, 
and  adhesive  strips,  cut  one  inch  and  a  half  in  width  and  long  enough  to 
reach  from  the  sternum  to  the  vertebi'al  spines,  are  tightly  applied,  ex- 
tending far  enough  above  and  below  the  broken  rib  to  cover  the  three  or 
four  adjacent  bones.  The  strips  should  overlap  about  one  half  of  their 
width. 

The  body  of  a  vertebra  may  be  broken  by  indirect  violence,  as  a  fall 
from  a  height,  the  patient  striking  on  the  head,  feet,  or  buttocks,  or  the 
bone  may  be  crushed  by  extreme  anterior  flexion  (occasionally  due  to 
muscular  action),  or  by  direct  injury,  with  or  without  penetration.  The 
character  of  the  injury,  pain,  and  symptoms  of  pressure  upon  the  cord 
or  nerves  will  lead  to  a  correct  diagnosis. 

The  treatment  is  quiet  in  bed,  with  extension  and  counter-extension 
in  the  earlier  stages,  and  later,  the  plaster  jacket,  with  jury-mast  head- 
extension  for  all  lesions  above  the  tenth  dorsal  vertebra.  Below  this 
point  the  jacket,  from  the  pelvis  to  the  axilla,  will  suffice. 

In  the  case  of  the  patient  from  whom  the  accompanying  cut  (Fig. 
328)  was  taken  there  was  a  fracture  at  the  dorso-lumbar  junction, 
which  involved  the  eleventh  and  twelfth  dorsal,  and  first  lumbar  ver- 
tebrje.  There  was  a  sharp  knuckle  at  the  last  dorsal  and  first  lumbar 
s|)ines.  He  was  injured  by  an  elevator  descending  upon  him  and  vio- 
lently flexing  the  spine.  Paraplegia  resulted,  with  incontinence  of 
ffeces  and  urine.  I  treated  him  by  extension  and  the  plaster-of-Paris 
jacket.     The  symi)toms  of  i)aralysis  gradually  disappeared,  and  now,  ten 


300 


A  TEXT-BOOK   ON   SURGERY. 


years  after  the  accident,  lie  walks  well,  and  does  not  suffer  from  incon- 
tinence. 

Fi'actnre  of  tlio  arfifnilrir  processes  is  of  less  frequent  occurrence. 

This  accident  results  from  extreme 
extension  (dorsal),  or  may  occur  from 
direct  or  indirect  violence. 

^Vllen  the  .sp/'/ioNn  processes  are 
broken,  the  lesion  may  occur  near  the 
extremity,  but  more  fi'equently  the 
laminated  expansion  is  the  seat  of 
fracture. 

The  indications  in  all  forms  of  in- 
jury to  the  vertebral  column  are  to 
relieve  pressure  upon  the  cord  and 
nerves,  and  insure  all  possible  fixa- 
tion. While,  from  the  anatomical 
construction  of  the  spinal  column, 
extension  is  limited  and  diflicidt  of 
accomplishment,  yet  it  may  be  ol>- 
tained  in  a  sufficient  degree  to  re- 
lieve the  injured  structures  from  the 
greater  part  of  the  superincumbent 
weight.  ^Yhen the bodiesare  injured, 
dorsal  extension  throws,  in  part,  the 
weight  from  the  spongy  bodies  on  to 
the  compact  processes.  AVhen  the 
plaster  jacket  can  not  be  worn,  Taylor's  or  Shafer's  brace  may  be  em- 
ployed mth  advantage. 

Fractures  of  the  sacrum  are  rare,  and,  when  occurring,  are  due  to 
direct  violence  by  penetrating  bodies,  or  to  falls  from  such  heights  that 
other  and  serious  complications  render  the  prognosis  grave. 

No  treatment  except  enforced  quiet  is  called  for  primai'ily.  When 
ostitis  and  necrosis  occur  as  a  result  of  comminution,  operative  interfer- 
ence may  be  required. 

Fracture  of  the  coccyx,  with  displacement  foi'ward,  is  not  uncommon. 
The  accident  occurs  from  a  fall  or  blow  directly  upon  the  tip  of  the  spine. 
The  symptoms  are  those  of  pressure  upon  the  rectum,  causing  difficult 
defecation,  proctitis,  and  at  times  fissure  or  ulcer.  Pain  is  always  pres- 
ent, and  is  due  to  infiammation  as  well  as  pressure  upon  the  fifth  sacral 
and  coccygeal  nerves  (coccyodynia).  The  (mly  treatment  is  removal  of 
this  bone,  which  is  almost  always  fcdlowed  by  relief. 

The  incision  is  made  over  the  bone,  in  the  posterior  median  line,  the 
muscular  attachment  being  divided  close  to  the  bone.  Care  must  be 
taken  to  avoid  wounding  the  posterior  plexus  of  veins,  or  the  rectum. 

The  wound  may  be  sewed  in  its  upi^er  portion,  leaving  the  lower  end 
open  for  drainage. 

Os  Innominafum. — Though  rarely  fractured  as  compared  with  other 
portions  of  the  skeleton,  the  ilium,  ischium,  or  pubes  may  be  broken 


Fig.  32S. — Fracture  of  the  vertehrse. 


FRACTURES.  301 

singly,  or  all  may  be  involved  in  a  common  lesion  at  the  acetabulum. 
The  force  causing  the  fracture  maybe  directly  applied,  or,  less  frequently, 
by  an  indirect  blow,  as  a  fall  on  the  foot  or  great  trochanter,  in  which  the 
head  of  the  femur  may  be  driven  into  the  acetabulum  with  such  violence 
as  to  cause  fracture. 

When  the  fracture  is  confined  to  the  iliac  crest  the  diagnosis  will  be 
determined  by  preternatural  mobility,  crepitus,  and  pain,  in  conjunction 
with  the  history  of  the  case.  When  the  bones  of  the  deeper  basin  are 
broken,  exploration  by  the  rectum  or  vagina  will  be  necessary. 

The  treatment  demands  reposition  and  rest.  AVhen  the  acetabulum 
is  involved,  extension  to  the  foot  and  leg  (Buck's  method),  with  the  foot 
of  the  bed  elevated,  should  be  practiced.  When  possible,  the  bed  should 
be  so  arranged  that  defecation  may  be  accomplished  without  lifting  the 
pelvis.  A  modification  of  Crosby's  fracture-bed  would  answer  this  pur- 
pose well.  Fixation  of  one  or  both  thighs,  including  the  pelvis  and  lower 
portion  of  the  abdomen  and  spine,  could  be  well  effected  by  surround- 
ing these  parts  with  a  plaster-of-Paris  dressing.  The  prognosis  will  de- 
pend, in  great  part,  upon  the  extent  of  the  injury  sustained  by  the  pelvic 
viscera. 

Fractures  of  the /ej7ivr  may  be  best  studied  in  three  groups,  viz. :  (1) 
of  the  upper  extremity  (including  the  neck  and  trochanter) ;  (2)  of  the 
shaft ;  (3)  of  the  lower  or  condyloid  extremity. 

Fracture  of  the  7iec7i  of  the  femur  may  take  place  wholly  within, 
partly  within  and  partly  without,  or  wholly  outside  of  the  capsule.  This 
accident  rarely  occurs  in  the  young  and  middle-aged.  It  is  a  lesion  of 
old  age,  and  women  suffer  more  than  men.  The  anatomical  cause  is 
chiefly  a  condition  of  senile  rarefaction,  which  begins  usually  about  the 
fiftieth  year.*  It  has  been  demonstrated  that  the  change  in  the  relation 
of  the  axis  of  the  neck  to  that  of  the  shaft  in  the  aged  is  not  enough  to 
account  for  the  greater  prevalence  of  this  accident  in  the  old,  nor  is  there 
a  marl-i:ed  diminution  of  the  animal  constituents  of  bone  at  this  time  of 
life.     The  change  is  one  of  senile  atrophy. 

Fracture  of  the  neck  of  the  femur  is  usually  caused  by  force  trans- 
mitted from  below  upward,  and  along  the  shaft  of  the  femur.  In  many 
instances  the  accident  is  trivial.  The  specimen  shown  in  Figs.  329  and 
330  was  taken  from  a  patient  who  broke  her  femur  while  in  the  act  of 
kneeling  in  church,  f  It  has  been  known  to  occur  even  whUe  turning 
over  in  bed.  The  line  of  fracture  may  be  at  any  part  of  the  neck,  and  in 
exceptional  cases  is  through  the  epiphysis.  When  the  fracture  is  near 
tlie  trochanteric  line,  or  when  these  tuberosities  are  involved,  it  is  usual- 
ly the  result  of  direct  violence— that  is,  a  fall  or  blow  upon  the  hip. 

The  diagnosis  of  fracture  of  the  neck  of  the  femur  may  be  detennined 
by  a  study  of  the  liistory  and  the  symptoms.     If,  after  a  fall  upon  the 

*  Prof.  L.  A.  Stimson,  "  Treatise  on  Fractures."     irenrv  C.  Lea's  Son  &  Co. 

t  This  patient  was  treated  by  Dr.  Selden,  of  Norfolk,  Va.,  and,  from  the  history  of  the  case, 
together  with  the  appearance  of  tlie  specimen,  I  consider  it  an  intrai-apsuhir  fracture,  witli 
osseous  union.  Prof.  F.  II.  IIuMiiltiin,  to  whom  I  sljowod  tlie  specimen,  considered  it  rather  a 
condition  of  senile  atrophy. 


302 


A  TEXT-BOOK   OX  SURGERY. 


foot  or  knee,  or  directly  ujion  the  trochanter,  there  results  pain  in  the 
hip,  etersion  of  the  foot,  loss  of  function  in  the  member,  sJiortening, 


y'\.rf'f%i}f^" 


Fig.  o. 


Fin.  3,30. 


and  crepitus,  fracture  at  the  neck  is  probable.      These  symptoms  are, 
however,  not  always  present.     Pain  is  the  most  constant,  eversion  is  the 

rule,  inversion  the  ex- 
ception, in  about  the 
proportion  of  eight  to 
one.  The  turning  out- 
ward of  the  leg  and  foot 
is  probably  due  to  grav- 
ity, and  when  inversion 
occurs  it  is  due  to  a 
peculiarity  in  the  lock- 
ing or  overlapping  of 
the  fragments.  Loss  of 
function  is  not  always 
entire,  for  in  some  in- 
stances— and  very  prob- 
ably in  impacted  fract- 
ures—  the  i^atient  has 
been  known  to  walk 
a  considerable  distance 
upon  the  limb  after  the 
fracture.  This  is,  how- 
r.,     .      ^    ,•   ,  .  .r.i    <■         ,  ■    r    ,       ,     ever,  a  rare  occurrence. 

-Showinc  the  displ.icement  of  the  fraimfnta  lu  fructure  ot  '  ... 

the  neck  of  tbe  femur.     (Atler  Gray.)  Shortening    IS   deter- 


ProrrottMis 
CCHCLLus     supenion 
OBTURATOR     INTERNUI 
CEMClLUs    iNFCniOlt 
OBTURATON     tKTERMUB 
OUADBRTUt     rCMORIX 


Fir..  331. 


FRACTURES. 


303 


miripcl  by  comparative  measurement  of  the  two  sides,  from  the  ante- 
rior superior  spine  of  the  ilivim  to  the  inner  malleolus.  The  internal 
malleoli  should  be  made  to  touch,  and  should  be  directly  in  a  line 
with  the  symphysis  pubis,  umbilicus,  and  interclavicular  notch.  The 
end  of  the  tape  should  be  held  on  the  thumb-nail,  and  pressed  well  into 
the  notch,  just  under  the  anterior  su^jerior  spine.  It  is  then  earned 
along  the  inner  side  of  the  thigh,  knee,  and  leg,  to  the  under  edge  of 
the  inner  malleolus.  The  degree  of  shortening  will  vary  from  one  fourth 
of  an  inch  up  to  two  or  more  inches.  The  occasional  nonnal  inequality 
in  the  length  of  the  two  lower  extremities  should  not  be  lost  sight  of. 
Tills  varies  from  one  eighth  to,  in  some  instances,  as  much  as  one  inch 
and  over.  To  determine  that  the  shortening  is  between  the  trochanter 
and  the  acetabulum,  apply  Nelaton^s  test ;  a  line  drawn  from  the  tuber- 
osity of  the  ischium  to  the  anterior  superior  spine  of  the  ilium  passes 
over  the  upper  surface  of  the  great  trochanter.  The  distance  the  tip  of 
the  trochanter  may  be  above  this  line  will  give  the  degree  of  shortening. 
Bryant's  test  is,  with  the  patient  resting  upon  the  back,  the  legs  parallel 
and  extended,  to  drop  a  line  from  the  anterior  superior  spine  and  to 
measure  the  distance  between  this  line,  at  its  nearest  point  to  the  tro- 
chanter and  this  tuberosity.  If  the  fracture  is  above  the  trochanter  the 
tuberosity  will  be  found  nearer  the  line  than  on  the  sound  side. 

Crepitus  can  not  always  be  obtained.  In  the  cases  of  impaction  it  is 
not  possible  without  the  employment  of  force  sufficient  to  unlock  the 
fragments,  and  in  many  cases  of  fracture  above  the  trochanteric  line, 
without  impaction,  crepitus  is  not  felt.  Any  unnecessary  manijiulation 
of  the  hi]3  is  contrary  to  the  best  rules  of 
practice,  and  an  effort  to  elicit  crei^itus 
should,  therefore,  not  be  made. 

It  is  difficult,  and  at  times  impossible, 
to  determine  at  what  particular  portion  of 
the  neck  the  fracture  has  occurred.  Prac- 
tically it  makes  little  difference,  as  the 
treatment  is  the  same. 

Treatment. — Rest  in  the  dorsal  decu- 
bitus, with  fixation  of  the  pelvis  and  the 
affected  limb,  are  the  immediate  indica- 
tions. To  secui-e  fixation,  extension  in  a 
limited  degree  is  desirable.  To  obtain 
this,  place  the  patient  upim  a  hard  mat- 
tress. If  the  bed  is  too  soft  and  yielding, 
place  wide  boards  underneath  the  top  mat- 
tress in  order  to  hold  it  smooth  and  firm. 
Elevate  the  foot  of  the  bedstead  from  six 
to  ten  inches,  by  placing  the  legs  at  this 
end  upon  Ijlocks  of  wood  or  bricks.     Cut 

two  stiips  of  strong  adhesive  plaster  (Maw's  moleskin  is  preferable) 
about  two  inches  wide  and  long  enough  to  extend  from  the  \\\\^  to  be- 
yond the  sole.     Lay  one  of  these  upon  the  inner  and  outer  surface  of  the 


Fio. 


"I'  the  neck  of  the 


fumur,  witU  imijaetion.     (Bigulow.) 


;504 


A  TEXT-BOOK  ON  SURGERY. 


thigh  and  leg,  exactly  opposite  each  other,  and  hold  them  in  f)lace  by 
V  well-adjusted  roller.  The  strips  can  be  more  nicely  applied  if  they  are 
partially  divided  with  the  scissors,  in  a  direction  upward  and  inward,  at 
intervals  of  about  two  inches.  Wlien  within  four  inches  of  the  anlde 
the  bandage  is  interposed  between  the  strips  and  the  integument.  In 
order  to  prevent  pressure  upon  the  malleoli,  a  stick  about  six  inches  in 
length  is  placed  between  the  ends  of  the  adhesive  strijjs,  and  the  exten- 
sion-weight is  attached  to  this. 

A  piece  of  board  provided  with  a  pulley  is  next  fastened  to  the  foot  of 
the  bed,  so  that  the  tip  of  the  pulley  will  be  on  a  level  with  the  malleoli. 
The  weight  will  vary  from  two  or  three  up  to  eighteen  pounds.  A  pound 
for  every  year  of  life  up  to  eighteen  is  the  rule  ;  but  this  is  too  much  for 
fracture  above  the  trochanter.  About  ten  pounds  is  sufficient  for  all 
ordinary  cases.  Shot  in  a  bag,  or  sn)oothing-irons,  are  usually  emjiloyed 
for  the  extension-weight,  which  is  tied  to  the  string  (Fig.  383).     The  pa- 


tient's body  serves  as  the  counter-extending  force,  the  gravitation  toward 
the  head  of  the  bed  being  about  counteracted  by  the  weight  attached  to 
the  foot.  Additional  benefit  and  comfort  may  be  obtained  by  laying 
small,  long  bags,  filled  with  sand,  on  either  side  of  the  thigh  and  leg. 
When  the  limb  tends  too  strongly  to  outward  rotation  (or  inversion) 
this  may  be  corrected  by  the  sand-bags,  or  by  Prof.  Hamilton's  long 
splint,  which  Is  shown  in  Fig.  333,  and  which  is  tied  by  strips  of  bandage 
from  tlie  axilla  to  the  ankle.  The  foregoing  is  practically  Buck's  ex- 
tension, to  which  may  be  added  Hamilton's  long  splint. 

In  some  instances  it  may  be  found  advantageous  to  use  Volkmann's 
sliding  foot-piece,  seen  in  Fig.  334.  This  consists  of  a  posterior  splint 
for  the  leg.  to  which  is  attached  a  foot-piece  having  the  angle  shown  in 
the  cut.  This  splint  should  be  perforated  for  the  heel,  and  rest  upon  two 
cross-bars  of  wood,  which  in  turn  slide  up  and  down  on  a  rectangular 
frame.     Upon  the  upper  edge  of  these  parallel  bars  a  tongue  is  cut,  and 


FRACTURES. 


305 


a  corresponding  notoli  or  gTOove  in  the  cross-bars.     This  apparatus  is 
complicated  and  will  rarely  be  needed.     Buck's  extension,  with  Hamil- 
ton's long  splint,  or  preferably  the  sand- bags,  wDl  meet  almost  every  re- 
quirement, and  give 
the    greatest   satis- 
faction. 

In  order  to  i)re- 
vent  the  bed-cloth- 
ing from  coming  in 
cf)ntact  with  the 
fractured  limb,  wire 
screens  (Figs.  335, 
336)  may  be  em- 
ployed. In  some 
instances  plaster  of 
Paris  may  be  used; 
but  this  method  of 
treating     fractures  ^"-  3^*-^'°>k-""'«  -^"^"s  »bot-piece. 

above  the  trochan- 
ter is  now  rarely 
employed. 

The  most  easily 
managed  and  simply  constructed  apparatus  for  making  the  necessary 
extension  and  counter-extension,    in  applying  the  fixed  dressing  for 
fractures  of  the  lower  extremity,  is  made  as  follows  : 

Into  each  end  of  a  ta- 
ble, about  five  feet  long, 
two  holes  are  bored,  and 
into  these  two  perpendic- 
ular pieces  are  fitted,  two 
feet  long  and  about  two 
inches  in  diameter,  while 
a  strong  horizontal  bar 
connects  the  two  upper 
ends.  One  of  these  up- 
rights is  smoothed,  round- 
ed, and  padded,  to  pre- 
vent injury  to  the  peri- 
njeum. 

The  foot  of  the  injured 
side  being  nicely  band- 
aged, the  patient  is  placed 
upon  the  table,  astride 
the  i)added  upright  (Fig. 
337),  with  the  perinaeum  against  it,  and  is  suspended  by  a  strap  passed 
over  the  horizontal  bar  and  underneath  the  sacrum,  being  elevated  from 
the  table  sufficiently  to  allow  free  manipulation  of  the  bandages  under 
the  back.  The  head  and  shoulders  are  sui)ported  upon  pillows,  the  foot 
20 


Fig.  335.— (After  Esmarcli.  \ 


Fio.  33ij. — [AtV-T  Esmarcli.) 


306 


A  TEXT-BOOK  ON  SURGERY. 


Fio.  337. 


of  the  uninjured  limb  rests  upon  a  stool,  a  elove-liitch  or  double  loop  is 
thrown  around  the  ankle,  and  to  this  a  block  and  pulley  is  attached,  the 
opposite  end  of  which  is  fastened  to  the  wall.     Extension  is  then  applied 

until,  by  measure- 
ment from  the  ante- 
rior sui)erior  spinous 
process  of  the  ilium 
to  the  lowest  point 
of  the  inner  malleo- 
bis,  the  two  legs  are 
found  to  be  of  the 
same  length.  The 
jielvis,  thigh,  and  leg 
are  then  covered  with 
a  dry  roller,  or  a 
trousers' leg,  or  j)iece 
of  soft  blanket,  and 
the  plaster  rollers 
applied.  Accessory 
splints  of  zinc,  coj^- 
per,  tin,  or  hoop-iron  may  be  worked  in  with  the  plaster  bandages  if 
desired. 

The  prognosis  in  this  class  of  cases  should  always  be  guarded.  Use- 
ful limbs  result  in  a  large  majority  of  cases,  but  the  function  of  the  hip 
is  not  often  fully  restored. 

Fracture  of  the  TrocJtanter.  —  Separation  of  the  great  trochan- 
ter is  a  rare  accident.  The  cause  is  direct  violence.  A  diagnosis  must 
rest  upon  independent  mobility  of  the  tuberosity,  with  crepitus. 
The  treatment  should  be  fixation,  firm  compressicm  by  bandages,  and 
rest. 

Fracture  through  the  Trochanters. — Fracture  through  the  trochan- 
ters is  also  comparatively  of  rare  occurrence.  The  diagnosis  may  be 
determined  by  shortening,  crejoitus,  pain,  and  loss  of  symmetry  and  func- 
tion. A  strong  diagnostic  feature  is,  that  a  portion  of  the  trochanter  may 
remain  attached  to  the  neck.* 

The  treatment  does  not  differ  from  that  just  given.  The  prognosis  is 
more  favorable  as  to  restoration  of  function.  Occasionally  enormous 
exostosis  occurs  after  fracture  at  this  locality. 

Fractures  of  the  Shaft. — The  shaft  of  the  femur  is  usually  broken  by 
direct  violence,  or  indirectly  by  a  force  transmitted  from  below  upward. 
In  exceptional  instances  the  fracture  is  caused  by  muscular  contraction 
alone.  The  line  of  fracture  is  generally  oblique,  and  the  displacement  is 
determined  chiefly  by  the  direction  of  this  line.  In  complete  fracture 
overlapping  is  the  rule.  When  the  break  is  in  the  upper  portion  the 
lower  fragment  is  drawn  iip  by  the  long  muscles  extending  from  the 
pelvis  to  the  neighborhood  of  the  knee-joint,  and,  as  shown  in  Fig.  338, 


*  Prof.  L.  A.  StimsoD,  op.  cit. 


FRACTURES. 


307 


tlie  upper  fragment  is  usually  rotated  outward  by  the  external  rotators, 
and  tilted  up  and  to  the  front  by  the  psoas  and  iliacus.  When  the  fract- 
ure is  near  the  knee-joint  the  lower  fragment  is  tilted  backward  by  the 
action  of  the  gastrocnemius,  popliteus,  and  plantaris  muscles.  The  up- 
per fragment  is  acted  iipon  in  a  milder  degree  by 
the  same  muscles  that  caused  its  displacement  in 
the  higher  fracture  (Fig.  339). 

Fractures  at  the  condyles  may  include,  trans- 
verse fracture  near  the  epi- 
physeal line,  or  through  the 
epiphysis  proper ;  transverse 
fracture,  -with  a  split  into  the 
intercondyloid  notch  ;  or  one 
or  the  other  condyles  may  alone 
be  broken  off. 

The  diagnosis  of  fracture 
of  the  shaft  of  the  femur  is  not 
difficult,  as  a  rule.  Preternat- 
ural moliility,  crepitus,  pain, 
and  shortening  will  usually  de- 
termine the  character  of  the 
injury.  When  the  joint  is  in- 
volved, in  addition  to  the  usual 
symptoms  of  fracture  the  knee 
becomes  much  swollen. 

Treatment. — In  the  treat- 
ment of  all  fractures  between 
the  trochanters  and  the  knee- 
joint  the  choice  rests  between 
the  method  by  Buck's  extension  and  the  plaster- 
of-Paris  dressing.  In  general  the  first  method  is 
preferable.  Unless  the  fracture  is  too  low  down, 
the  traction  of  the  adhesive  strips  should  be  upon  the  condyles  as  well 
as  upon  the  leg  below.  Even  when  it  is  determined  to  employ  the  gyp- 
sum fixed  dressing,  it  is  wise  to  defer  its  application  until  after  all 
danger  of  swelling  is  past,  usually  after  from  four  to  eight  days.  ^Vhen 
the  fracture  is  below  the  middle  of  the  thigh  the  plaster-of-Paris  dress- 
ing may  lie  applied  without  anaesthesia.  The  bandages  need  not  extend 
higher  than  the  level  of  the  perina?um.  After  a  few  days  the  patient 
may  move  about  on  crutches.  In  the  higher  fractures  the  same  prin- 
ciples are  involved  as  in  fractures  of  the  neck.  When  the  knee-joint 
is  involved,  passive  motion  should  be  commenced  on  the  third  week, 
and  continued  at  intervals  thereafter.  Whatever  method  is  emjiloyed, 
immobilization  at  the  seat  of  fracture  should  be  maintained  for  five  or 
six  weeks. 

In  fracture  of  the  femur  in  children  the  plaster-of-Paris  dressing  is 
to  be  preferred.  The  reposition  of  the  fragments  should  be  made  un- 
der anaesthesia,  and  the  parts  immediately  immobilized.     This  class  of 


SCMJ.  rfMOIK. 


Fig.  339. — Displacement 
of  tiagnicnts  in  fract- 
ure of  the  thigb  in  the 
lower  third.  (Alter 
tirav.) 


Fig.  338.  —  Displacement  of 
fi-ai;ments  in  fracture  of 
the  thigh  in  the  upper 
third.     (After  Gray.; 


308 


A  TEXT-BOOK   ON  SURGERY. 


patients  are  not  easily  controlled  and  kept  quiet  by  the  use  of  the  ordi- 
nary apparatus.* 

Patella. — Frnctui'e  of  the  i)atellii  may  bo  caused  by  violent  contrac- 
tion of  the  qua(lrice])s  extensor  muscle,  or  by  a  ))low  or  fall  upon  tliis 
bone,  ni-  lioth  of  these  factors  may  combine  to  cause  this  lesion.  The 
line  of  cleavage  is  usually  transverse,  and  in  the  majority  of  instances 
just  below  the  middle  of  the  ])atella.  It  may,  however,  be  broken  in  an 
oblique  or  longitudinal  direction,  or  in  several  directions  at  once — "  stel- 
late fracture." 

When  muscular  contraction  is  the  chief  or  sole  factor  in  this  break, 
the  line  of  cleavage  is  usually  transverse.  Longitudinal  and  stellate 
fractures  are  the  result  of  direct  violence.  Fracture  of 
the  patella  is  usually  complete,  the  separation  of  the 
fragments  varying  from  a  small  fraction  of  an  inch  up 
to  two  or  more  inches.  The  separation  is  generally 
more  marked  on  the  internal  than  the  external  border. 
In  rare  instances  incomplete  fracture  may  occur,  the 
cartilage  not  giving  way.  Such  cases  are  scarcely  rec- 
ognizable without  exploration,  the  few  recorded  being 
seen  post-mortem. 

Fracture  of  the  patella  is  more  frequent  in  men 
than  in  women,  and  occurs  mostly  in  the  decades  from 
the  twentieth  to  the  fortieth  years. 

The  diagnosis  may  be  made  from  loss  of  function, 
pain  at  the  seat  of  injury,  and  separation  of  the  frag- 
ments. Inability  to  extend  the  leg,  or  marked  impair- 
ment of  function,  is  always  ju-esent.  The  limb  may, 
however,  be  used  to  support  the  body  if  it  is  allowed 
to  fall  into  the  straight  position.  One  of  my  patients, 
with  a  separation  of  three  fourths  of  an  inch,  walked,  unaided,  a  quar- 
ter of  a  mile  immediately  after  the  accident.  TTjemorrhage  between  the 
fragments  occurs  in  all  cases,  and  therefore  communicates  with  the  syno- 
vial membranes,  which  are  interposed  between  the  posterior  surface  of 
the  patella  and  the  general  cavity  of  the  joint,  and,  in  cases  where  the 
separation  is  well  marked  (from  half  to  one  inch  and  over),  it  is  more 
than  probable  that  the  reflection  of  the  synovial  lining,  from  the  low- 
er anterior  portion  of  the  joint  below  the  patella  upward  and  forward 
to  the  front  of  the  intercondyloid  notch,  is  torn,  and  that  whatever 
of  extravasation  occurs  is  into  the  general  cavity  of  the  joint.  This 
occurred  in  the  only  knee  I  have  opened,  immediately  after  this  fract- 
ure. More  or  less  effusion  into  the  joint  follows  in  the  large  majority 
of  cases.  In  longitudinal  and  stellate  fractures  the  separation  is  usually 
slight. 

Treatment. — A  patient  with  a  broken  knee-pan  should  be  immediately 


Fio.  340.  —  Displiicc- 
jnent  of  fragments 
in  fracture  ol  the  pa- 
tella.  (After  Gray . ) 


*  In  one  instance,  in  tlie  case  of  a  child  tliree  and  a  half  years  old,  with  a  fracture  at  the 
middle  of  the  thigh,  chloroform  narcosis  was  obtained  during  natural  sleep,  the  child  not  he- 
coming  conscious  while  passing  under  the  influence  of  the  anesthetic. 


FRACTURES.  309 

put  to  bed,  in  the  dorsal  decubitus,  the  affected  limb  kept  straight,  and 
the  foot  and  leg  elevated  on  i)illo\vs.  In  case  of  swelling  and  inflamma- 
tion at  the  Ivuee,  cold  cloths  or  the  ice-bag  should  be  apijlied.  The 
mechanical  treatment  should  commence  at  once. 

A  posterior  splint  is  made  to  extend  from  near  the  heel  to  the  gluteal 
fold.  Shellac-board  is  best  suited  for  this  purpose,  but  sole-leather, 
gutta-percha,  or  a  piece  of  plank  will  sufiice,  if  these  lighter  articles  can 
not  be  obtained.  If  either  of  the  first  three  articles  is  employed,  the  piece 
should  be  cut  wide  enough  to  envelop  from  one  half  to  two  thirds  of  the 
circumference  of  the  limb.  Tkree  inches  above  and  below  the  center  of 
the  knee-joint  a  tongue,  one  inch  wide  and  two  inches  long,  should  be  cut, 
and  turned  out  so  that  the  attached  end  is  nearest  the  joint.  The  sjilint 
is  dipped  in  warm  water  until  soft  enough  to  be  molded  to  the  part,  when 
it  is  lined  with  a  sheet  of  absorbent  cotton  and  applied  on  the  posterior 
aspect  of  the  limb.  The  cotton  ru"  padding  material  should  be  consider- 
ably thicker  opposite  the  jjopliteal  space,  in  order  to  prevent  complete 
extension  of  the  leg.  Secure  the  upper  and  lower  ends  by  turns  of  the 
roller  thrown  around  the  thigh  and  ]eg,  and  next  begin  the  oblique 
or  approximating  turns  by 
carrying  a  flannel  bandage 
around  the  leg,  so  that  it 
catches  behind  the  lower 
tongue,  w^hence  it  is  carried 
obliquely  upward  above  the 
upper  fragment,  across  the 
quadriceps,  and  back  to  the 
starting-point.  This  is  con- 
tinued until  the  upper  frag-      ,.,,,,,•,,  .    ^ 

^  ^  °  iiG.  311.— Uumilton's  apparatus  tor  fracture  ot  the  patella. 

ment  is  brought  into  appo-  (Uamiiton.) 

sition  with  the  lower.     For 

the  lower  fragment   the  bandage  is   made   to  catch  behind  the  upper 

tongue  upon  the  splint.      When  the  fragments  are  approximated  the 

entire  limb  is  invested  by  the  roller. 

After  the  dressing  is  applied  the  same  jiosition  is  maintained  for  two 
weeks.  The  portion  of  the  bandage  immediately  over  the  fracture  should 
be  opened  on  the  fifth  or  sixth  day,  and  a  careful  inspection  made,  in 
order  to  determine  whether  the  roller  has  slipped  and  re-separation  oc- 
curred. If  tlie  bandage  is  at  all  loose  it  should  be  tightened,  but  never 
drawn  so  tightly  that  it  produces  any  discomfort. 

This  inspection  should  be  repeated  every  five  or  six  days,  but  the 
splint  is  never  taken  off  until  the  fourth  week,  when  passive  motion  at 
the  knee-joint  should  be  made.  In  doing  this  the  surgeon  should  grasp 
the  patella  between  the  thumbs  and  fingers,  in  order  to  hold  the  frag- 
ments firmly  in  contact,  and  while  thus  held  should  have  an  assistant 
move  the  leg  back  and  forth,  not  flexing  it  for  the  first  time  more  than 
15°  or  20°.  This  should  be  repeated  each  week  until  the  ninth  week,  and 
twice  a  week  after  this  for  the  next  two  or  three  months.  After  the  first 
two  weeks  the  patient  may  be  allowed  to  sit  uj)  in  bed,  or  to  be  moved 


310  A  TEXT-BOOK   ON   SURGERY. 

upon  a  sofa  or  chair  about  the  room.  Al'ter  I'oui'  wcfka  he  may  be  per- 
mitted to  move  about  on  crutches.  Except  when  passive  motion  is  being 
made,  the  splint  should  be  worn  ni^lit  and  day  for  the  iii'st  ten  weelvs 
after  the  injury.  After  tins  it  may  be  removed  after  retiring  for  the 
night  and  adjusted  before  rising.  The  long  splint  and  ligure-of -eight 
bandnging  about  tlie  knee  should  V)e  worn  for  si.\;  montlis,  to  prevent  a 
re-separation.  After  six  months  it  may  be  shortened  to  a,  length  of 
eigliteen  inches,  and  tliis  or  a  strong  leather  flexion-check  shoidd  be  worn 
for  the  next  twelve  months.  After  eigliteen  months  of  careful  watching, 
such  a  ligamentous  unicm  will  not  give  way,  except  under  conditions 
which  would  brenk  the  bone.  In  two  cases  which  came  under  my  ob- 
servation (the  patients  both  males,  one  forty  and  the  other  about  fifty- 
live  years  old)  tin?  ligamentous  union  was  so  strong  that,  several  years 
after  the  first  accident,  they  suffered  a  second  injury,  and  the  u])per  frag- 
ment parted  transversely,  the  ligament  holding  intact.  The  foregoing 
method,  which  is  practically  that  of  Prof.  Ilamiltcm,  is  by  far  the  most 
preferable  treatment  for  this  injury. 

Many  innovations  have  been  made  in  the  treatment  of  this  fracture, 
some  of  which  are  unnecessary,  others  unjustiiial)le.  Among  the  fomier 
may  be  mentioned  asplratlun  of  the  effusion  into  the  joint  and  between 
the  fragments.  This  should  only  be  done  when  the  capsule  is  distended 
in  an  extraordinary  degree.  The  most  unjustifiable  method  of  ti'eatment 
ever  introduced  in  this  fracture  is  that  of  opening  into  the  joint  and 
wiring  the  fragments  together.  Unjustifiable  because,  first  of  all,  it  is 
dangerous  ;  secondly,  it  is  unnecessary.  A  careful  observance  of  the  rule 
of  practice  just  laid  down  will  secure  a  ligamentous  union,  with  a  resto- 
ration of  the  function  of  the  extremity,  equally  as  good  in  many  cases  as 
that  enjoyed  before  the  injury,  and  in  the  vast  majority  of  cases  equal 
to  all  the  ordinary  requirements  of  the  limb,  and  this  is  accomi)lished 
without  the  slightest  risk  to  tlie  patient's  life,  and  with  no  distuibance 
of  his  comfort  beycmd  confinement  to  bed  for  two  weeks,  to  the  room  f(n' 
four  weeks,  and  to  his  crutches  and  cane  for  about  six  months. 

On  the  other  hand,  although  an  osseous  union  may,  in  tlie  majority 
of  cases,  be  obtained,  the  restoration  of  function  is  not  more  complete, 
the  confinement  in  bed  is  longer,  and  the  danger  to  life  and  the  integrity 
of  the  part  sufficiently  great  to  deter  the  surgeon  from  employing  this 
method  of  practice. 

In  September,  1881,  induced  by  the  reported  successes  after  this 
operation,  I  wired  a  fractured  patella  on  the  twentieth  day  after  the  ac- 
cident, in  the  case  of  a  woman  twenty  years  old.  The  strictest  antisep- 
tic pi'ecautions  were  employed,  and  free  drainage  was  secured.  Osteo- 
arthritis with  destruction  of  the  joint  resulted,  and  the  patient  barely  es- 
caped with  her  life,  the  limb  having  been  amputated  in  the  lower  third 
of  the  thigh.*  Another  patient,  in  the  hands  of  a  New  York  surgeon, 
died  as  a  result  of  this  operation.     If  the  full  histories  of  all  these  cases 

*  For  a  full  report  of  this  case,  and  a  synopsis  of  otlier  cases,  see  the  author's  paper  in 
the  "  Medical  Record,"  vol.  xxi,  1882. 


FRACTURES. 


311 


were  written  I  think  few  surgeons  would  have  the  temerity  to  repeat  the 
procedure. 

Introducing  v/ires  beneatli  the  two  fragments,  from  above  downward, 
without  cutting  the  integument,  and  securing  approximation  by  twisting 
in  front  of  the  Joint,  is  also  unjustifiable.  The  use  of 
Malgaigne's  hooks  is  also  unnecessary. 

The  plaster-of-Paris  method  is  employed  by  some 
operators  ;  but  it  is  not  to  be  preferred  to  the  method 
of  Hamilton.  In  this  procedure  the  fragments  are  ap- 
proximated by  adhesive  strips.  One  piece  is  cut  in 
the  shape  shown  in  Fig.  342,  the  broad  part  of  which 
is  applied  just  above  the  up2)er  margin  of  the  upper 
fragment,  and  fastened  here  by  a  roller.  The  entire 
limb  is  now  covered  by  a  bandage  wliich  leaves  ex- 
posed the  two  narrow  strips  of  the  adhesive  plaster. 
Over  this  the  plaster  bandages  are  ajjplied,  strong  trac- 
tion being  made  upon  the  adhesive  strips  in  order  to 
hold  the  fragments  approximated  until  the  gypsum 
hardens.  The  limb  should  be  enveloped  from  the 
anlile  to  the  perina^um. 

In  old  fractures,  with  wide  separation  of  the  frag- 
ments and  permanent  loss  of  function  of  the  extensor 
muscles,  the  best  prothetic  apparatus  is  a  strong  leath- 
er shield  worn  around  the  knee.     This  prevents  too  much  flexion,  and 
I)artly  stiffens  the  joint. 

Many  cases  of  wide  separation,  however,  retain  the  function  of  the 
limb  in  a  remarkable  degree.     In 
a  case  occurring  in  my  practice. 


^xm 


Fio.  34-2.— Gauutlc't  of 
adliesive  plaster  for 
exerting  traction  on 
the  upper  fragment 
of  a  tractui'ed 
tella. 


pa- 


Fio.  343. 


FiQ.  344. — Wide  separation  nf  rnriiiiifuts  (tV.'Ui  a  to  A). 
witli  perlect  funetiou  of  liuib. 


from  which  the  two  accompanying  cuts  were  taken,  there  is  a  separation  of 
more  than  three  inches  with  the  leg  tiexed  (Fig.  3-43),  and  nearly  one  inch 


312  A  TEXT-BOOK  ON  SURGERY. 

and  a  half  in  extension  (Fig.  344) ;  yet  this  patient  has  perfect  use  of  the 
limb.  No  approximation  of  the  fragments  was  ever  attempted  in  this 
patient.  ITe  was  kei)t  in  bed,  witli  the  log  elevated,  for  six  weeks,  and 
an  ordinary  roller  apjilied  after  this,  witliout  any  effort  at  bringing  the 
fragments  together. 

Ln)ifiifii(Jiii<il  fractures  of  the  jKitella  should  be  treatfd  by  fixation  of 
the  muscles  of  tlie  tliigh  and  leg,  and  lateral  approximation  of  the  frag- 
ments by  flannel  bandages,  well  applied  over  a  thin  layer  of  absorbent 
cotton. 

Stellate  fractures,  in  which  the  air  is  not  admitted  to  the  joint,  should 
be  treated  by  Hamilton's  method. 

In  compound  fractures  of  the  patella  in  which  the  joint  is  laid  open, 
the  cavity  of  the  joint  should  be  carefully  drained  and  strict  antisepsis 
employed.  If  the  fragments  are  widely  separated,  and  can  not  be  kept 
in  api»roxiniation,  strong  catgut  or  fine  wire  sutures  may  be  employed  to 
hold  them  in  position.     Such  instances  will  rarely  occur. 

Leg. — Fracture  of  one  or  both  bones  of  the  leg  occurs  next  in  fre- 
quency to  that  of  the  radius  and  ulna.  The  upper  end  of  the  tibia  is 
usually  broken  by  direct  violence,  although  a  fall  from  a  height  upcm  the 
foot  may  produce  a  longitudinal  or  oblique  fracture  communicating  with 
the  joint.  The  separation  sometimes  takes  place  through  the  epiphysis. 
The  most  common  point  of  fracture  is  the  junction  of  the  middle  and 
lower  third.  The  fibula  may  be  broken  at  the  same  level,  or  at  a  point 
removed  from  the  line  of  fracture  in  the  tibia,  ov  this  last  bone  alone 
may  be  broken. 

Near  tlie  ankle-joint  fracture  of  one  or  both  Ijones  is  not  uncommon. 
While  a  complete  double  fracture  below  the  junction  of  the  middle  and 
lower  third  is  rare,  a  partial  fracture  of  the  tibia  (malleolus)  and  a  com- 
plete break  of  tlie  fibula  is  comparatively  frequent.  In  this  (Pott's) 
(fracture  (called  also  railroad  or  street-car  fracture,  since  it  is  often  caused 
by  jumping  from  a  car  in  moticm)  the  foot  is  powerfully  everted,  the 
inner  malleolus  bent  forcibly  inward,  and  the  strain  falls  upon  the  inter- 
nal lateral  ligament  of  the  ankle  joint,  the  internal  malleolus,  the  external 
malleolus,  and  outer  tip  of  the  articular  surface  of  the  tibia.  As  the  force 
is  continued,  either  the  internal  lateral  ligament  or  the  inner  malleolus 
must  yield,  and,  as  usual  in  this  test  between  ligament  and  bone,  the 
latter  yields.  As  a  rule,  the  osseous  rim  is  torn  off  with  the  ligament,  or 
the  entire  malleolus  is  wrenched  off  at  a  higher  point.  The  pressure  upon 
the  inner  aspect  of  the  external  malleolus  forces  this  outward,  and  the 
fibula  above  is  bent  inwai'd  and  usually  breaks  at  between  two  and  three 
inches  above  the  tip  of  the  malleolus.  If  gi-eat  force  is  exercised  in  the 
production  of  this  fracture,  the  inferi(jr  tibio-fibular  ligament  may  be  torn 
away,  or,  more  likely,  the  outer  lip  of  the  articular  surface  of  the  tibia 
broken  off.  In  exceptional  instances,  inversion  of  the  foot  will  produce 
fracture  of  the  inner  malleolus  by  direct  pressure  of  the  astragalus,  and 
of  the  external  malleolus  or  fibula  by  tniction  on  the  external  lateral 
ligament. 

In  fracture  of  the  tibia  alone  the  displacement  will  be  determined  by 


FRACTURES. 


313 


the  direction  of  the  line  of  fracture.  Marked  overlapping  or  displace- 
ment is  prevented  by  the  unbroken  fibula.  In  the  upper  portion,  with  a 
transverse  fracture,  the  deformity  is  slight.  At  the  lower  and  middle 
third  the  obliquity  is  usually  considerable,  and  from  below  upward  and 

backward  (Fig.  345).     The  upper  fragment 
l'\l  L  111  is  tilted  forward  by  the  action  of  the  quad- 

riceps extensor,  and  partly  by  the  pressure 
of  the  upper  end  of  the  lower  fragment, 
which  is  thrown  in  the  same  direction  by 
the  contraction  of  the  sural  muscles  and 
the  consequent  lifting  of   the  heel.     The 


Fig.  345. — Displacement  of  troiriucnts  in 
fracture  of  the  tibia,  near  tlie  .iune- 
tion  of  the  lower  and  middle  third. 
(Atler  Gray.) 


Fio, 


346. — Displacement  of  the  frasments  in  Pott's  fracture. 
^Aftc■r  Gray.) 


deformity  in  Potfs  fracture  is  shown  in  Fig.  346.  In  complete  fracture 
of  both  bones  of  the  leg,  overlapping  and  displacement  are  the  rule. 

Dlar/nosis. — Fracture  of  the  fibula  alone  may  exist  without  detection, 
although  a  careful  examination,  with  direct  pressure,  will  usually  elicit 
crepitus  or  reveal  the  j^oint  of  fracture  by  abniu-mal  mobility  and  pain. 
Fracture  of  the  tibia  is  easily  made  out  by  palpation  along  the  spine, 
crepitus,  loss  of  symmetry,  and  pain.  Tliese  symptoms,  together  with 
the  history  of  the  accident,  Avill  leave  little  room  for  doubt  in  any  case. 
Pott's  fracture  is  recognized  by  the  peculiar  eversion  of  the  foot,  the  ab- 
normal prominence  of  the  internal  malleolus,  pain,  and  loss  of  function. 
Crepitation  of  the  fragments  of  the  malleoli  may  be  elicited,  and  preter- 
natural mobility  in  the  fibula,  at  a  point  two  or  three  inches  above  the 
tiji  of  tlie  outer  malleolus.  In  inversion  with  fracture  the  outer  malleolus 
is  prominent.  Fracture  of  both  bones  is  easily  made  out  by  the  deform- 
ity, abnormal  mobility,  and  crepitation. 

Treatment. — In  most  cases  of  fracture  of  one  or  both  bones  of  the  leg 
it  is  the  best  practice  to  reduce  the  displacement  by  extension  and  coun- 


314 


A  TEXT-BOOK  ON   SURGERY. 


ter-exteiision,  ami  to  fix  tlie  \n\it  m  the  possition  of  least  discomfort  for 
from  four  to  six  days,  or  until  all  danger  of  swelling  is  past.  After 
this  time  no  method  is  so  generally  satisfactory  as  the  plaster-of-Paris 
dressing. 

To  meet  the  first  indication  the  fracture-box  (Fig.  347)  is  a  most  use- 
ful apparatus.     It  consists  of  a  bottom,  a  foot-piece,  and  two  movable 


iio.  347. — Fracture-box. 

side-pieces.  This  may  be  placed  upon  a  pillow  or  box  to  give  it  a  slight 
elevation,  or  the  apparatus  may  be  modified  after  Petit's  box,  seen  in  use 
in  Fig.  848. 

If  any  extension  is  needed  it  may  be  secured  by  a  bandage  around  the 
ankle  and  foot,  wliich  is  also  passed  through  the  holes  in  the  foot-piece. 
In  fixing  the  leg  in  this  fracture-box  the  sides  are  turned  down,  a  thick 


Fig.  3-18.— Petit's  fracture-box.     (After  Stimson.) 

layer  of  cotton  or  some  soft  material  arranged  for  the  leg  to  rest  upon, 
and  shaped  to  fit  the  natural  contour  of  the  calf.  The  sides  are  also 
packed,  turned  into  position,  and  fastened.  As  soon  as  the  first  swelling 
subsides,  or  as  soon  as  it  is  evident  that  no  marked  swelling  wiU  occur, 
the  plaster  of  Paris  should  be  applied.  This  dressing  should  extend  at 
least  half  way  up  the  thigh,  in  all  cases,  in  order  to  fix  the  knee-joint. 
It  is  applicable  to  all  fractures  of  one  or  both  bones,  from  the  knee  down 
to  and  including  the  malleoli.     Extension  can  usually  be  made  from  the 


FRACTURES. 


315 


heel  and  ankle  by  an  assistant.  A  dry  muslin  or  flannel  roller  is  first 
applied,  and  the  plaster  bandages  laid  on  over  this.  A  thin  layer  of  ab- 
sorbent cotton  is  at  times  jjlaced  between  the  first  dry  roller  and  the  leg 
(Fig.  349).  If  swelling  should  occur,  the  plaster  cast  should  be  split  down 
the  middle  line,  in  front  and  behind,  and  replaced,  but  not  so  tightly. 
When  such  a  di-essing  requires  frequent  removal  it  is  best  to  line  the  cut 


Fig.  349. — Plaster-of-Paiis  drcssiutf  in  fracture  of  leg. 


edges  of  the  cast  with  adhesive  strips,  and  to  make  hinges  along  the  pos- 
terior seam  out  of  the  same  material.  At  the  end  of  four  weeks  all  splints 
should  be  removed,  passive  motion  made  at  the  knee  and  ankle,  and  the 
apparatus  reapplied  and  worn  for  at  least  two  weeks  more.  Passive 
motion  should  be  repeated  each  week. 

In  applying  the  plaster  in  Potts  fractiire  the  eversion  needs  to  be 
overcome  and  the  straight  position  maintained  while  the  gypsum  is  hard- 
ening. To  accomplish  this  a  piece  of  adhesive  plaster  about  two  inches 
A\ide  is  laid  along  the  fibula  side  of  the  leg,  as  high  as  the  upper  two 
thirds,  extending  down  over  the  external  malleolus,  and  across  the  sole 
of  the  foot  to  the  inner  side.  A  miislin  roller  is  next  passed  around  the 
ankle  over  the  inner  malleolus.  These  tuberosities  should  be  protected 
by  bits  of  absorbent  cotton.  An  assistant  steadies  the  ankle  by  traction 
on  the  roller,  while  the  foot  is  brought  into  straight  position  by  traction 
on  the  adhesive  strip.  The  plaster  is  now  applied,  and  the  foot  held  in 
position  Tintil  the  cast  hardens. 

When  plaster  of  Paris  can  not  be  had,  starch  is  next  in  order,  or 
splints  of  felt,  leather,  book-binder's  board,  metal,  or  wood  may  be  em- 
ph)yed. 

Compound  fractures  of  the  leg  are  treated  by  immediate  reduction  of 
the  deformity,  by  free  drainage,  and  strict  antiseptic  precautions.  For 
perfect  fixation,  and  at  the  same  time  leaA*ing  the  wound  open  for  in'iga- 
tion  and  inspection,  the  interrupted  or  the  fenestrated  plaster-of-Paris 
dressing  is  the  most  generally  useful.  If  the  injury  is  slight  and  lim- 
ited, tlie  fenestrated  dressing  is  preferalile.  Extension  is  made  from  the 
foot,  and,  after  reposition  and  drainage  are  secured,  the  plaster  band- 
ages are  applied.  As  soon  as  the  dressing  sets,  windows  large  enough 
to  permit  of  free  inspection  are  cut  immediately  over  the  wound  and 
at  the  points  of  exit  of  the  drainage-tul)es  below.  A  wire  loop,  worked 
into  the  plaster  or  tied  around  the  leg  after  hardening  has  taken  place, 
will  serve  as  a  medium  for  susiiending  the  limb  at  any  required  height 
(Fig.  3.-i0). 


316 


A  TEXT-BOOK   ON   SURGERY. 


The  interrupted  plaster  dressing  is  more  difficult  of  iipplication.  The 
entire  leg  and  foot,  and  half  way  iip  the  thigh,  are  covered  with  a  dry 
flnnnf'l  or  muslin  roller,  which  passes  over  the  wound,  retaining  the  sub- 
liauite  and  iudof'oriu  gauze  iu  place.     A  strong  piece  of  bar-iron,  or  two 


350. — Fcncsti'atcd  plaster-of-l'aris  dressing  for  Uxatiou  u:id  tiiroujfli- 
UruiiiUKe  ill  cnuii«iuiid  Iructures. 


or  three  thicknesses  of  hoop-iron,  or  a  twist  of  from  four  to  six  ordinary 
telegraph-wii'es,  is  now  shaped  to  follow  the  outline  of  the  foot  and  leg 
up  to  within  three  inches  of  the  wound  and  exits  of  the  drainage-tubes, 
at  which  point  it  is  bent  up  for  several  inches,  and  passes  over  the  wound 
much  like  the  handle  of  a  valise  (see  Fig.  351).  As  soon  as  a  point  three 
inches  above  the  wound  is  reached  it  is  again  made  to  conform  to  the 


atffftrffrnfrrrm^rsauvi'ilPVfi-vi 


Fig.  351. 


shape  of  the  leg  and  thigh.  A  separate  straight  piece  of  iron,  or,  if 
needed,  two  pieces,  about  sixteen  inches  in  length,  are  also  prepared.  A 
layer  of  absorbent  cotton  is  placed  around  the  leg  and  thigh  before  the 
tirst  bandage  is  applied,  and  over  this  the  plaster  rollers  are  carried, 
above  and  below  the  fracture,  to  within  three  inches  of  the  wound. 
After  several  layers  of  bandage  (generally  three  thicknesses)  have  been 
applied,  this  much  is  allowed  to  harden,  and  upon  this  the  long  iron 
splint  is  laid,  in  front,  and  the  short  pieces  posteriorly  and  laterally  (out 
of  the  way  of  the  drainage-tubes),  and  are  tixed  by  additional  turns  of 
tlie  plaster  bandages  and  by  plaster  mortar  worked  in  with  the  hands. 
That  portion  of  the  bar  which  is  shajjed  like  the  handle  of  a  valise  should 
be  stiffened  by  winding  around  it  several  thicknesses  of  the  plaster  roll- 
ers, and  adding  a  sufficient  quantity  of  plaster  mortar.  Suspen.sion  is 
made  from  the  ends  and  center  of  the  ware. 


FRACTURES.  317 

The  fracture-box  may  be  employed  when  plaster  can  not  be  ob- 
tained. 

Foot. — The  bones  of  the  tarsus  may  be  broken  by  direct  or  indirect 
violence. 

The  diagnosis  is  not  always  easily  made.  The  best  method  of  treat- 
ment is  fixation  with  a  plaster-of-Paris  dressing,  after  all  danger  of  swell- 
ing has  passed.  When  the  os  calcis  is  broken,  and  the  tuberosity  drawn 
up  by  the  sural  muscles,  the  leg  should  be  flexed  well  upon  the  thigh, 
and  the  tarsus  extended  in  order  to  relax  this  gi'oup  of  muscles. 

Fracture  of  the  metatarsal  bones  and  phalanges  should  be  treated  in 
the  same  manner  as  the  corresponding  bones  of  the  upper  extremity. 

Ununited  Fractures — Fibrous  Union. — In  a  certain  proportion  of 
cases  union  between  the  ends  of  broken  bones  is  delayed  beyond  the  time 
usually  required  for  ossification,  and  may  remain  permanently  ununited. 

The  causes  of  ununited  fracture  are :  (1)  Failure  to  secure  immobility  ; 
(2)  presence  of  muscle,  tendon,  nerve,  or  other  substance  between  the 
fragments ;  (3)  violent  and  prolonged  inflammation  of  the  broken  bones 
and  the  surrounding  soft  parts  ;  (4)  any  intercurrent  disease  w^hich  inter- 
feres with  nutrition  ;  (5)  a  too  great  separation  of  the  fragments.  If  the 
ends  of  broken  bones  are  not  kept  in  contact,  and  at  the  same  time  im- 
movable, fibrous  union  may  result,  for  by  motion  the  provisional  callus 
is  injured,  and  may  disappear  by  absorption  as  a  result  of  continued 
irritation.  If  the  fi'agments  overlaj),  so  that  no  portion  of  the  broken 
surface  of  one  side  is  in  contact  with  that  of  the  opposite  end,  no  matter 
how  well  adapted  the  dressing  may  be,  muscular  contraction  may  retard 
or  prevent  union. 

The  intervention  of  any  of  the  soft  tissues,  or  any  foreign  substance, 
may  prevent  the  formation  of  callus,  and  lead  to  fibrous  imion. 

Ostitis  after  fracture  may  lead  to  destruction  of  the  fragments,  and  of 
the  shafts  of  bone,  to  such  an  extent  that  imion  can  not  occur.  Instances 
are  on  record  where,  resulting  from  fracture,  rarefying  ostitis  has  de- 
stroyed the  entire  bone. 

Any  general  condition  of  impaired  nutrition  increases  the  liability  to 
fibrous  union.  Rickets,  osteomalacia,  syphilis,  scrofula,  tuberculosis,  or 
any  acute  febrile  disease  supervening  upon  fracture,  tends  to  interfere 
with  or  to  delay  bony  union  after  fracture. 

When  by  any  reason  the  broken  surfaces  are  separated,  osseous  union 
will  probably  not  occur.  This  accident  and  result  are  exemplified  in 
fracture  of  the  j)atella,  where  fibrous  or  ligamentous  union  is  the  great 
rule. 

The  diar/nns/'s  of  fibi'ous  union  is  determined  from  continued  preter- 
natural mobility  at  the  seat  of  fracture  after  two  months  have  elapsed. 
Crepitus  is  not  to  be  depended  upon,  as  the  ends  of  the  fragments  may 
be  rounded  off  by  absorption,  and  covered  over  with  inflammatory  newly 
fomied  material,  or  at  times  with  cartilage. 

Treatment. — The  immediate  indication  is  to  correct  any  constitutional 
condition  which  may  be  present,  and  to  increase  general  nutrition. 
Syphilis,  or  any  recognized  dyscrasia,  must  be  specially  treated.     In  the 


318  A  TEXT-BOOK   ON  SURGERY. 

administration  of  tonics,  cod-liver  oil,  witli  the  hypophosphites  of  lime 
and  soda,  should  play  an  important  part. 

It  is  of  importance  to  lix  the  l)roken  part  immovably  by  the  plaster- 
of-Paris  or  other  solid  dressing.  Tliis  should  be  removed  after  four 
weeks,  in  order  to  allow  passive  motion  of  any  articulation  near  the  seat 
of  fractui-e,  and  necessarily  included  in  the  dressing.  After  the  first 
movement  of  the  joint  the  dressing  slutuld  be  reapplied  and  the  passive 
motion  repeated  each  week.  Great  care  should  be  observed  to  prevent 
motion  at  the  seat  of  fracture.  If,  after  the  lapse  of  fir  mi  ten  to  fourteen 
weeks,  there  are  no  indications  of  union,  a  mild  iulhiuiiuatiou  should  ))e 
induced  in  the  tissues  immediately  about  the  fracture.  This  may  be 
accomplished  by  forcibly  rubbing  the  ends  of  the  bones  together  (after 
an  amesthetic  has  been  administered),  and  then  investing  the  member 
with  the  gypsum  dressing.  In  obstinate  cases  more  radical  measures 
may  need  to  be  adopted.  A  favorite  practice  is  to  cut  down  ujion  the 
fracture,  dissect  away  any  ne\v-fonned  tissue,  and  saw  olf  the  ends  of  the 
bones,  back  far  enough  to  reach  healthy  and  well-nourished  bone. 

It  may  sometimes  suffice  to  cause  inflammation  and  stimulate  bone- 
formation  by  pimcturing  the  skin  with  an  awl  or  drill,  and  with  the  point 
of  this  instrument  scraping  the  ends  of  the  fragments. 

If  these  measures  fail,  the  bones  should  be  freshened  and  brought 
together  by  silver-wire  sutures,  as  advised  in  fracture  of  the  jaw,  or  by 
transfixion  with  movable  steel  drills,  in  the  same  manner  as  given  in 
excision  of  the  knee-joint. 


♦ 


CHAPTER  XIII. 

STJKGEKT   OF  THE  ARTICULATIONS. 

Dislocations. — A  dislocation  is  the  displacement  of  the  articular  sur- 
face of  one  bone  from  its  normal  relation  with  another.  Dislocations  are 
traumatic,  pathological,  and  congenital.  They  are  also  partial  or  com- 
plete, simple,  complicated,  and  compound. 

Traumatic  dislocations  are  sudden,  and  result  from  violence  ;  patho- 
logical when,  from  disease  of  the  joint,  the  bones  and  liijaments  are  more 
or  less  desti-oyed ;  congenitcd  when,  from  failure  of  development,  the 
normal  contiguity  of  the  articular  surfaces  can  not  be  maintained.  A 
dislocation  is  said  to  be  ])artial  when  any  portion  of  the  articular  sur- 
faces are  still  in  contact ;  complete  when  one  articular  end  overlaps  the 
other  ;  simple  when  there  is  no  other  lesion  than  displacement  and  injury 
of  the  capsule  ;  complicated  when  there  exists  with  the  dislocation  a 
fracture  into  the  joint :  compound  when,  by  reason  of  a  wound,  the  air 
is  in  contact  with  the  dislocated  surfaces.  Again,  a  dislocation  may  be 
recent  or  ancient,  the  limit  of  the  former  variety  being  from  a  few  hours 
to  two  or  three  weeks.  A  primitive  luxation  is  one  in  which  the  dislo- 
cated surfaces  retain  the  same  position  as  at  the  time  of  the  accident, 
secondary  when  another  position  is  assumed. 

In  a  dislocation  the  capsule  may  be  ruptured,  or  simply  stretched 
mthout  a  solution  of  its  continuity.  When  great  violence  is  employed 
in  producing  it,  the  muscles,  tendons,  nerves,  vessels,  fascia,  and  skin 
about  the  joint  may  be  more  or  less  involved.  The  changes  which  follow 
are  ])ractically  those  of  acute  synovitis,  arthritis,  or  peri-arthritis. 

Dislocations  occur  chiefly  in  adult  life,  and  are  most  frequent  in 
those  joints  which  enjoy  the  greatest  freedom  of  motion,  and,  at  the 
same  time,  are  subjected  to  the  heaviest  strains.  The  condition  of  the 
individual,  the  tonicity  of  the  muscles,  and  the  strength  of  the  liga- 
ments, have  a  great  deal  to  do  with  the  frequency  of  dislocations.  All 
things  being  equal,  patients  with  poorly  develojied  muscles  and  relaxed 
ligaments  are  more  prone  to  these  lesions  than  the  well  developed  and 
vigorous. 

The  diagnosis  of  a  dislocation  rests  chiefly  upon  abnormal  immobility 
and  asymmetry.     Pain  is  usually  present. 

Special  Dislocations — Inferior  Maxilla. — Displacement  of  the  con- 
dyles of  the  lower  jaw,  from  its  articulation  with  the  temporal  bone,  may 
occur  on  one  or  both  sides ;  usuallv  it  is  bilutei-al.     The  condyles  slip 


320  A  TEXT-BOOK   ON   SURGKRY. 

l■ol•^\  arc!  uial  are  engaged  partly  beneath  tlie  zygoma,  in  front  of  the  emi- 
nentia  articularis,  and  partly  between  the  zygoma  and  the  temporal 
fossa.  Museiilar  action  alone  may  produce  this  luxation,  or  it  may  be 
caused  by  external  violence. 

The  fujrnptoms  are  great  pain,  difficult  deglutition,  and  indistinct 
articulation  (especially  of  the  labial  sounds).  The  lower  teeth  aie  unusu- 
ally advanced,  the  mouth  is  widely  ojjened,  and  the  saliva  trickles  over 
the  lips. 

In  unilateral  luxation  the  chin  points  toward  the  sound  side,  and  the 
teeth  are  less  widely  separated. 

In  the  diagnosis  the  chief  point  of  differentiation  is  fracture  at  or  near 
the  condyle.  In  fi-acture  the  condyle  may  possibly  be  recognized  in  its 
normal  position  by  palpation  ;  immobility  is  not  marked  ;  the  mouth  is 
not  opeued  ;  crepitus  nuiy  be  obtained. 

Reduction. — In  bilateral  displacement,  wrap  the  thumbs  with  sev- 
eral layers  of  bandage  or  cloth,  to  protect  them  from  being  bitten  when 
reduction  is  accomplished.  Place  one  thumb  along  the  inferior  molars 
of  each  side,  and  the  fingers  beneath  the  body  of  the  jaw  ;  press  down- 
ward and  backward  with  the  thumbs,  while  the  fingers  lift  the  chin 
upward. 

Or  place  a  thick  roll  of  leather,  piece  of  wood,  or  firm  cork,  between 
the  u])per  and  lower  j)()sterior  molars  of  each  side,  and  upon  these,  as  a 
fulcrum,  lift  the  chin  upward,  and  at  the  same  time  push  backward  in  the 
direction  of  the  socket. 

If  both  of  these  methods  fail,  they  should  be  repeated  under  ether. 
It  may  sometimes  be  advisable  to  attempt  the  reduction  of  one  side  by 
either  of  the  above  methods,  and  retain  it  in  position  while  reducing  the 
other. 

After  reduction  is  completed  \n\t  on  a  head  and  chin  figure-of-8 
bandage,  and  allow  it  to  remain  for  a  week  (Fig.  24),  or  apply  Hamil- 
ton's head-stall  for  fracture  of  the  lower  jaw  (Pig.  311).  In  several  in- 
stances, where  the  dislocation  has  become  permanent,  the  symptoms  have 
gradually  subsided,  and  a  fair  degree  of  motion  and  usefulness  acquired 
through  the  false  joint. 

ClaiHcle. — The  sternal  end  maybe  displaced /or?o«r^  on  the  manu- 
brium, upward  above  the  sternum,  backward  behind  the  manubrium. 
The  last  two  varieties  are  rare.  The  cause  of  the  first  form  is  usually 
force  applied  to  the  shoulder  with  the  arm  thrown  backward.  In  the 
case  of  a  boy  fifteen  years  old,  treated  by  myself,  the  displacement  was 
caused  by  a  comrade  catching  him  by  both  shoulders,  placing  his  knee 
in  the  middle  of  the  back,  between  the  shoulder-blades,  and  violently 
pulling  the  shoulder's  back. 

The  diagnosis  is  not  diSicult,  the  reduction  easy,  but  the  maintenance 
of  the  bone  in  position  difficult.  A  compress,  covered  with  adhesive 
plaster  to  prevent  slipping,  placed  upon  the  bone  after  reduction,  and 
firmly  held  in  place  by  a  roller,  is  a  proper  method  of  treatment.  The 
arm  should  be  fixed  with  Sayre's  apparatus  for  fractured  clavicle,  in 
order  to  prevent  a  repetition  of  the  luxation. 


DISLOCATIONS. 


321 


The  outer  end  of  the  clavicle  may  be  displaced  above  or  below  the 
acromion  process,  and  above  or  in  front  of  the  coracoid  process.  Dis- 
placements under  the  acromion  and  in  front  of  the  coracoid  are  very- 
rare. 

The  symptoms  are  very  distinct,  and  the  reduction  not  surrounded 
with  great  difficulty.  When  replaced,  however,  the  bone  is  with  diffi- 
culty maintained  in  position.  By  drawing  firmly  outward  upcm  the 
shoulder  of  the  affected  side,  and  pressing  the  clavicle  downward  into 
position,  reduction  will  be  successfully  accomplished.  Place  a  firm  com- 
press over  the  end  of  the  bone,  bend  the  forearm  at  right  angles  to  the 
arm,  and  carry  (me  or  two  strong  strips  of  adhesive  plaster  over  the  com- 
press, behind  the  shoulder,  along  the  arm  to  the  olecranon,  and  again  by 
the  front  over  the  compress.  Re-enforce  this  by  a  bandage,  and  place  the 
arm  in  a  sling.  If  luxation  recurs,  tighten  the  adhesive  strips,  and  place 
the  arm  in  a  Velpeau's  bandage.  To  apply  this  bandage,  place  the  hand 
of  the  affected  side  almost  upon  the  oppo- 
site shoulder,  fixing  a  wad  of  cotton  be- 
neath each  axilla.  Lay  the  end  of  a  roller 
on  the  shoulder-blade  of  the  sound  side, 
and  carry  the  bandage  over  the  acromial 
end  of  the  clavicle  of  the  injured  side,  and 
the  front  of  the  ann  for  a  short  distance, 
l^assing  obliquely  to  the  under  surface  at 
the  elbow,  and  around  beneath  the  well  ax- 
illa to  the  point  of  starting.  Repeat  this 
to  secure  the  roller,  and  then  carry  the 
bandage  horizontally  around  the  chest  and 
over  the  tip  of  the  elbow.  The  oblique  and 
horizontal  turns  are  alternated  until  the 
shoulder  and  arm  are  completely  enveloped 
(Pig.  3.52). 

Ilumervs,  at  the  Shoulder. — Disloca- 
tion at  the  shoulder-joint  is  by  far  the  most 
frequent.  It  may  take  place  in  three  direc- 
tions— bacl'ward,  under  the  spine  of  the 
scaj^ula  {subacromial  and  sabsp/'nous)  ; 
downward.,  below  the  glenoid  cavity  {subglenoid) ;  and  forxoard,  be- 
neath the  coracoid  or  clavicle  {suhcoracoid  or  siibclaricular). 

The  first  variety  is  of  rare  occurrence.  The  subacromial  dislocation  is 
only  a  partial  displacement,  and  becomes  complete  when  the  head  of  the 
bone  passes  well  beneath  the  sjjine  of  the  scapula  (Fig.  3531  The  sub- 
glenoid is  comparatively  frequent,  occurring  in  about  the  same  propor- 
tion of  cases  as  the  subcoracoid.  Displacement  forward  under  the  clav- 
icle is  rare.  On  account  of  the  coraco-acromial  ligament,  and  the  addi- 
tional protection  aft"orded  to  the  joint  above  by  the  acromion  process, 
dislocation  directly  upward  can  scarcely  occur. 

In  the  subglenoid  luxation  the  capsule  is  stretched  or  torn  along  its 
lower  surface,  and  the  head  of  the  humerus  rests  upon  the  margin  of  the 
21 


FiQ.  352. — Velpeau's  bandage. 
Stimson.) 


(Alter 


322 


A  TEXT-BOOK  ON   SURGERY. 


glenoid  cavity  iu  a  partial  dislocation,  or,  if  the  caj^sule  is  torn,  it  (usu- 
ally) slips  in  front  of  the  long  tendon  of  the  triceps,  and  is  lodged  upon 
the  axUlary  border  of  the  scajiula,  immediately  below  the  articular  sur- 


Fio.  353.  —  Subacro- 
mial and  ■  subsni- 
Dous.     (Bryant.) 


Fig.  354.— Subglenoid, 
(Bryant.) 


Fio.  355.— Subcoracoid. 
(Bryant.) 


Fio.  35G.— Subcla- 
vicular.   (Bryant.  J 


Fia.  357. — Subglenoid.     (Bryant.) 


face  (Fig.  354).  The  supra-spinatus  muscle  is  severely  stretched,  and 
either  suffers  rupture  of  its  tendon  or  substance,  or,  rather  than  yield,  it 
may  tear  off  a  rim  of  the  upper  facet  of  the  greater  tuberosity.     The 

long  head  of  the  biceps  and  the  coraco- 
brachialis  are  also  subjected  to  great 
strain  or  rupture,  while  the  tension  of  the 
deltoid  holds  the  arm  in  a  position  with 
the  elbow  slightly  tilted  from  the  side  of 
the  body. 

Among  the  less  frequent  complica- 
tions of  this  le-sion  may  be  mentioned 
pressure  upon  the  cinnimtiex  and  axil- 
lary nerves,  and  injury  or  rupture  of  the 
great  vessels. 

The  cause  of  this  dislocation  is  vio- 
lence applied  to  the  shoulder  in  a  direc- 
tion from  above  do^vnward,  or  indirectly  to  the  hand,  forearm,  or  elbow, 
with  the  humerus  raised  at  or  beyond  an  angle  of  90°  to  the  axis  of  the 
trunk. 

The  diagnosis  of  a  subglenoid  luxation  will  depend  upon  the  follow- 
ing symptoms  :  Tlie  acromiim  process  is  unu.sually  prominent,  the  head 
of  the  bone  is  not  in  its  normal  relation  to  this  jn-ocess,  and  may  be  felt 
low  down  in  the  axillary  space.  There  is  a  depression  in  the  anterior 
axillary  fold  iu  these  subjects.  The  arm  is  fixed  in  such  a  manner  that 
the  elbow  points  directly  outward  from  the  side  of  the  body  (Fig.  357). 
As  in  all  the  shoulder  dislocations,  the  arm  is  so  held  that,  if  the  hand 
of  the  injured  side  be  placed  on  the  opposite  shoulder,  the  elbow  can  not 
be  made  to  di'op  down  upon  the  wall  of  the  thorax.  This,  the  test  of 
Dugas,  is  important  in  differentiation  from  fracture  in  which  there  is 
such  a  considerable  degree  of  motion  possible  that  the  arm  can  be  broiight 
well  down  upon  the  chest.     There  is  always  preternatural  immobility  in 


DISLOCATIONS. 


323 


a  dislocation.  Another  excellent  method  of  differentiation  is  that  of 
Callaway,  based  upon  the  fact  that  the  circumference,  measured  over 
the  acromial  end  of  the  clavicle  and  the  acromion,  and  through  the 
axilla,  is  in  a  dislocation  much  increased  over  the  normal,  or  over  that 
present  in  fracture  at  the  neck.  Crepitus,  when  obtained,  wHl  deter- 
mine a  fracture. 

Reduction — First  Mdliocl. — Place  the  patient  upon  a  table,  bed,  or 
upon  the  floor.  For  the  left  shoulder  the  operator  removes  the  shoe  from 
the  left  foot  and  places  it  in  the  axilla,  against  the  thorax.     He  now 


iV 


Fig.  35S.— (Erichsen.) 

seizes  the  arm  and  forearm  of  the  patient,  carries  it  out  at  a  right  angle 
to  the  axis  of  the  patient's  spine,  and  makes  jwwerful  traction  in  the 
direction  of  the  glenoid  cavity.  While  this  is  being  effected  the  arm  is 
brought  inward,  parallel  with  and  against  the  side  of  the  body  (Fig. 
358).  The  foot  not  only  serves  to  effect  counter-extension,  but  is  also 
used  as  a  fulcrum  for  lifting  the  head  of  the  bone 
over  the  edge  of  the  glenoid  facet  into  the  articular  \P7>^. 

cavity  of  this  process.  If  this  can  not  be  accom- 
plished without  ether,  after  one  or  two  trials  the  an- 
aesthetic should  be  given.  After  reduction  a  shoul- 
der-cap of  book-binder's  board,  leather,  or  gutta- 
percha should  be  applied,  and  worn  for  at  least  one 
week. 

Second  Method. — Fix  the  scapula  by  placing  a 
folded  sheet  or  long  cloth  around  the  body,  so  that 
the  upper  margin  of  the  cloth  will  touch  the  axillary 
folds.  The  ends  are  inti'usted  to  an  assistant,  who, 
standing  on  the  sound  side,  makes  counter-exten- 
sion. The  surgeon  now  takes  hold  of  the  arm  about  fio. 
its  middle  with  one  hand,  and  near  the  elbow  ^^•ith 
the  other,  and  carries  it  slowly  and  steadily  away  fi'om  the  body,  and 


(Brj-aot.) 


324 


A  TEXT-BOOK   ON   SURGERY. 


Fig.  360.— (After  Hamilton.) 


in  the  direction  of  least  resistance.  Wlien  it  is  at  a  right  angle  to 
the  axis  of  the  body,  strong  traction  is  made,  with  slight  axial  rota- 
tion.     If   the   manoeuvre   is   still   iinsnccessful,    carry  the   aim  higher, 

until  extension  is  made  in  the  line  of  the 
axillary  border  of  the  scapula  (Fig.  359). 

Third  Method. — Place  the  patient  in  a 
chaii',  so  that,  with  the  foot  of  the  opera- 
tor on  the  edge  of  the  seat,  his  knee  will 
come  snngly  into  the  axilla.  Place  one 
hand  npcm  the  shoulder  to  steady  it,  while 
tlie  other  seizes  the  aim  near  the  elbow. 
With  the  knee  as  a  fulcrum,  use  the  hu- 
merus as  a  lever,  which,  being  depressed, 
carries  the  head  of  the  bone  into  position 
( 1 'ig.  360).  Extension  from  the  forearm, 
and  counter-extension  through  the  me- 
dium of  the  opposite  arm,  may  also  be 
employed. 

8ubcoracotd  and  SubdaiHcular  Dislo- 
cation.— In  the  first  of  these  two  disloca- 
tions the  head  of  the  humerus  rests  upon 
and  in  front  of  the  inner  rim  of  the  gle- 
noid cavity,  and  Just  underneath  and  in  contact  with  the  coracoid  pro- 
cess (Fig.  355).  The  strain  upon  the  long  head  of  the  biceps  and  supra- 
spinatus  is  not  so  great  as  in  the  preceding  variety,  while  that  upon 
the  infra-spinatus  is  more  severe.  The  ten- 
dons of  the  coraco-brachialis  and  short  head 
of  the  biceps  rest  anterior  to  and  upon  the 
displaced  head.  The  rupture  of  the  capsule 
is  below  and  in  front. 

The  cause  of  this  displacement  is  violence 
applied  directly  to  the  shoulder,  from  without 
inward  and  forward,  or  to  the  elbow  or  hand 
when  held  in  an  extended  position. 

The  symptoms  and  methods  of  diagno- 
sis are  in  general  the  same  as  those  of  the 
subglenoid  luxation,  the  principal  difference 
being  in  the  appreciable  location  of  the 
head  of  the  bone  just  below  the  coracoid  pro- 
cess,   and    on    a   plane    considerably   higher 

than'  in  the  lower  displacement  (Fig.  361).  The  distance  from  the  acro- 
mion to  the  olecranon  is  shorter  in  this  than  in  the  subglenoid  dis- 
placement. 

The  suhdaincular  variety  of  this  forward  di.slocation  is  only  an  exag- 
geration of  the  subcoracoid,  in  which  the  head  of  the  bone  slips  under- 
neath and  internal  to  the  coracoid,  and  rests  against  the  serratus  mag- 
nus  and  behind  the  pectoralis  minor,  below  the  clavicle  (Fig.  356).  The 
causes  are  the  same,  and  the  symj^toms  differ  in  little  else  than  the  pres- 


Fio.  361.— Subcoracoid.     (Bryant.) 


DISLOCATIONS. 


325 


ence  of  the  head  of  the  humerus  nearer  to  the  clavicle.  The  arm  stands 
slightly  out  from  the  body,  and  the  elbow  is  tilted  backward.  The  ten- 
sion on  the  posterior  scapular  muscles  is  gi-eater,  and  rupture  of  their 
attachments  often  occurs,  while  the  anterior  insertion  of  the  subscapu- 
laris  may  be  dissected  up.  Pressure  on  the  axillary  vessels  and  nerves 
is  more  marked  in  this  luxation. 

The  rupture  of  the  capsule  occurs  on  its  anterior-inferior  aspect. 

The  treatment  of  the  subclavicular  variety  consists  in  judicious  exten- 
sion and  counter-extension  in  the  line  of  displacement,  until  the  head  of 
the  bone  is  carried  into  the  subcoracoid  position. 

The  subcoracoid  dislocation  may  be  reduced  by  the  method  just  de- 
scribed for  the  subglenoid  ;  that  is,  with  the  foot  in  the  axilla  as  a  ful- 
crum. This  will  rarely  fail,  and,  if  the  patient  is  etherized,  is  easily 
accomplished. 

The  subglenoid  irnd  suhcoracoid\\\x.a.t\ons  maybe  reduced  by  manipu- 
lation, as  follows  :  ^Vith  the  patient  fully  anaesthetized  (for  the  right 
side),  grasp  the  shoulder  with  the  right  hand,  placing  the  thumb  upon 
the  head  of  the  bone,  and  the  fingers  over  the  clavicle  and  spine  of  the 
scapula,  and  the  flexed  forearm,  near  the  elbow,  with  the  left  hand. 
Carry  the  elbow  out  from  the  side,  make  firm  extension,  and  slowly 


Fig.  3C2.— (Bn-ant.) 


Fio.  363.— Brvant.t 


rotate  the  humerus  outward  on  its  axis  (Fig.  362).  The  elbow  should 
now  be  raised  and  the  arm  made  to  describe  a  semicircle  in  the  direc- 
tif)n  of  the  sternum  and  face,  and  then  suddenly  brought  down  to  the 
side  of  the  thorax,  the  head  of  the  humerus  at  the  same  time  being  ro- 
tated inward  (Fig.  303).  The  thumb  of  the  opposite  hand  should  give 
the  right  direction  to  the  head  of  the  bone.     (Thomas  Bryant.) 

The  subacromial  and  suhspinoiis  dislocations  are  reducible  by  exten- 
sion and  counter-extension  in  the  line  of  displacement.  Counter-exten- 
sion may  be  made  by  an  assistant  holding  the  arm  of  the  sound  side,  or 
by  the  folded  sheet  (already  described)  apyjlied  just  in  the  axilla.  The 
operator  makes  extension  from  the  arm  and  forearm,  imparting  to  the 
humerus  a  slight  axial  rotation. 

General  Considerations. — Recent  dislocations  at  the  shoulder  may 
not  always  be  reduced,  and  some  which  are  readily  replaced  are  with 


326  A  TEXT-BOOK   ON   SURGERY. 

difficulty  held  in  position,  lluptnre  of  any  nniscle,  or  group  of  muscles, 
renders  the  luxation  subject  to  recurrence,  since  there  is  no  antagonism 
to  tlie  reniiiiniui;'  muscles.  Ev<»n  when  reposition  is  eflecti'd  and  7iia1n- 
tained,  the  functiuii  of  the  joint  may  be  permanently  impaired  on  account 
of  injury  to  the  surrounding  structures.  Injury  of  the  circunitlex  nerve 
has  been  followed  by  atropliy  of  the  deltoid  and  teres  minor,  while  trau- 
matism of  the  great  cords  of  tlie  axillary  i)lexus  and  injury  of  the  ves.seLs 
have  led  to  impairment  or  loss  of  function  in  the  extremity.  Ligature  of 
the  subclavian  aitery  and  amputation  have  been  necessitated  after  dislo- 
cation of  the  shoulder-joint. 

These  injuries  may  occur  at  the  time  of  the  displacement,  or  they  may 
be  produced  by  a  lack  of  skill  or  the  employment  of  too  great  force  in 
the  efforts  at  reduction. 

After  one  or  two  days  from  the  date  of  a  luxation  at  the  shoulder  (as 
elsewhere)  the  difficulties  of  reduction  increase,  and  ai'e  in  geneial  pro- 
portionate to  the  length  of  time  which  has  elapsed  since  the  accident. 
At  the  expiration  of  the  first  week  inflammatory  adhesions  occur,  and 
the  cavity  of  the  joint  is  in  part  filled  with  the  products  of  inflammation. 
In  rare  cases  reduction  has  been  accomplished  at  the  end  of  three,  six, 
and  twelve  months. 

The  propriety  of  attempting  reduction  in  ancient  shoulder  luxations 
will  depend  upon  the  individual  case.  It  will  frequently  occiu'  that,  in 
tile  new  position,  attachments  are  formed,  with  ligaments,  cartilage,  and 
synovial  membrane,  with  fair,  yet  limited,  motion  in  the  false  joint, 
which,  together  with  the  free  mobility  of  the  scapula  upon  the  thorax, 
gives  a  useful  degree  of  motion  to  the  arm.  Under  such  conditions  any 
attempt  at  reposition  is  unnecessary. 

In  well-selected  cases,  where  an  ancient  dislocation  can  not  be  reduced 
by  any  other  means  consistent  with  safety  to  the  tissues  about  the  joint, 
and  where  motion  is  so  limited  that  the  usefulness  of  the  arm  is  seriously 
impaired,  direct  incision,  under  strict  antiseptic  precautions,  may  be 
employed,  and  reduction  thus  efi'ected,  with  or  without  excision  of  the 
head  of  the  humerus.  After  the  head  of  the  bone  is  returned  to  its  nor- 
mal position,  drainage  should  be  secured  through  the  rent  or  incision  in 
the  capsule.  A  Neubefs  bone-drain,  or  a  soft  rubber  tube,  may  be  em- 
ployed, and  should  be  so  placed  that  it  will  lead  downward  from  the  most 
dependent  portion  of  the  capsule. 

Dislocations  at  the  Elbow-Joint. — The  upper  end  of  the  radius 
may  be  displaced  forward  on  to  the  anterior  surface  of  the  humerus, 
near  the  coronoid  fossa,  or  backward  upon  the  olecranon  process.  The 
anterior  displacement  is  met  with  somewhat  more  frequently  than  the 
posterior. 

In  the  displacement  forward  the  orbicular  and  a  portion  of  the  external 
lateral  and  anterior  ligaments  are  ruj^tured  ;  in  the  opposite  luxation 
only  the  first  two  are  lacerated. 

The  forward  displacement  is  caused  by  direct  violence  applied  to  the 
posterior  aspect  of  the  upper  end  of  the  radius,  or  by  falling  upon  the 
palm  of  the  hand  while  the  forearm  is  completely  extended,  the  full  force 


DISLOCATIONS.  327 

of  the  contraction  of  the  biceps  being  thus  added  to  the  force  transmitted 
along  the  shaft  of  the  bone. 

Si/mptoms. — Careful  palpation  -will  reveal  the  abnormal  presence  of 
the  head  of  the  radius  near  the  center  of  the  humerus,  while  pressure 
along  the  outer  condyle  will  demonstrate  its  absence  from  its  natural 
position.     The  forearm  is  semiilexed  and  slightly  pronated. 

Treatment. — Flex  the  arm  and  push  the  head  of  the  bone  forcibly 
downward  in  the  direction  of  the  articulation.  When  reduction  is  ac- 
complished place  a  compress  over  the  upper  end  of  the  bone  and  the 
external  condyle,  and  bind  it  firmly  in  position.  The  arm  should  be 
snugly  bandaged,  and  carried  in  a  sling  for  several  weeks. 

The  backward  dislocation  is  I'ecognized  by  the  jiresence  of  the  head  of 
the  bone  in  an  abnormal  position  near  the  olecranon,  behind  the  external 
condyle. 

Treatment. — While  an  assistant  makes  strong  extension  and  counter- 
extension  from  the  hand  and  arm,  the  operator  makes  direct  pressure 
upon  the  head  of  the  bone,  forcing  it  in  the  direction  of  the  articulation. 
As  the  displacement  is  being  corrected  the  assistant  should  carry  the 
forearm  in  a  position  of  supination.  The  after-treatment  consists  of  a 
compress  and  bandage,  worn  for  several  weeks. 

The  jjrogjios/s  of  this  injury  is  generally  not  favorable,  since  it  is  very 
apt  to  recur  after  reduction,  and  may  become  permanent.  A  fair  degree 
of  usefulness  is  maintained,  however,  in  many  cases  of  chronic  luxation 
of  this  end  of  the  radius. 

Complete  forward  dislocation  of  the  ulna  alone,  at  the  elbow,  can  not 
occur  without  fracture  of  the  radius  or  extensive  laceration  of  the  radio- 
ulnar ligaments. 

Dislocation  of  bot7i  radius  and  ulna  at  the  elbow  may  take  place  in 
all  directions. 

The  dislocation  backward  may  be  produced  by  falling  upon  the  hand 
with  the  forearm  almost  extended  ;  by  a  blow  uj^on  the  anterior  aspect 
of  the  forearm,  near  the  elbow,  a  blow  upon  the  posterior  surface  of  the 
humerus,  in  its  lower  portion,  or  force  applied  at  the  same  time,  in  oppo- 
site directions,  upon  these  surfaces.  The  coronoid  process  will  be  found 
lodged  in  the  olecranon  fossa,  the  upper  end  of  the  radius  restiug  on  the 
posterior  aspect  of  the  external  condyle. 

The  anterior  ligament  and  the  anterior  fasciculi  of  the  external  and  in- 
ternal lateral  ligaments  are  torn  loose,  and  in  extreme  cases  the  orbicular 
ligament  may  give  way,  although  the  yielding  of  the  external  ligament 
usually  saves  the  circular  ligament  from  being  torn.  The  tendon  of  the 
brachialis  anticus  is  stretched  or  is  broken  loose  fi'om  the  coronoid  pro- 
cess. Pressure  upon  the  brachial  artery  may  be  so  great  that  pulsation 
at  the  wrist  is  diminished  or  absent,  while  in  extreme  cases  the  median, 
ulnar,  or  musculo-spiral  nerves  may  be  injured. 

The  usual  position  of  the  forearm  is  one  of  almost  complete  extension, 
with  pronation.  Measurement  from  the  inner  condyle  to  the  stjdoid 
process  of  the  ulna  will  denu)nstrate  shortening.  Muscular  rigidity  is 
marked,  and  motion  of  the  displaced  bones  difficult  and  painful.     From 


328 


A  TEXT-BOOK   ON  SURGERY. 


these  symptoms  the  diagnosis  can  be  readily  made.  If  swelling  has 
ensued,  and  the  tumefaction  is  great,  it  is  not  always  easy  or  i)ossiJ)le  to 
recognize  the  character  of  the  injury.  Under  such  conditions  it  is  wise 
to  reduce  the  swelling  by  rest  and  local  application  for  a  few  days,  until 
the  exact  character  of  the  luxation  may  be  determined. 

Treatment — Red urtiun— Method  ofAstlei^  Cooper.— V^ith.  the  patient 
seated  in  a  chair,  the  operator  places  his  foot  on  the  seat  so  that  the 

anterior  aspect  of  the  patient's  forearm  will 
be  brought  in  contact  with  the  anterior  sur- 
face of  the  surgeon's  knee.  The  forearm 
should  now  be  grasj)ed  near  the  wrist  and 
forced  flexion  made,  using  the  knee  as  a 
fulcrum,  and  at  the  same  time  as  a  point  of 
resistance  to  the  extension  made  by  pull- 
ing upon  the  forearm  (Fig.  364). 

Flexion  unlocks  the  coronoid  process 
from  the  olecranon  fossa,  and  extension 
cari'ies  both  bones  forward  into  position. 
Unless  the  operator  is  j^ositive  that  perfect 
reduction  has  been  accomplished,  the  joint 
should  be  freely  flexed  and  extended  to 
test  its  working  capacity.  Care  must  be 
taken  to  hold  the  muscles  in  check  while 
this  manipulation  is  going  on,  for  fear  the 
bones  may  again  slij)  out  of  place.  Band- 
age the  arin  and  forearm,  and  apply  a 
splint,  which  should  be  worn  for  a  w^eek 
or  two.  When  an  ana?sthetic  is  used  the 
recumbent  posture  should  be  maintained.  The  bare  foot  may  be  utilized 
instead  of  the  knee. 

A  cloth  or  sheet  folded  around  the  arm,  just  above  the  elbow,  may  be 
used  for  counter-extension. 

Liston  advised  strong  extension  from  the  forearm,  and  counter-exten- 
sion from  the  shoulder,  with  the  arm  and  forearm  held  straight. 

Dislocation  of  the  radius  and  ulna  forward,  without  fracture  of  the 
olecranon,  is  of  rare  occurrence,  and  is  always  the  result  of  great  violence. 
Rupture  of  the  posterior  and  lateral  ligaments  occurs,  and  the  triceps 
tendon  is  torn  or  greatly  stretched,  while  the  brachialis  anticusand  biceps 
are  relaxed.  The  posterior  portion  of  the  olecranon  rests  upon  the  ante- 
rior articular  aspect  of  the  humerus,  or  may  slip  into  the  coronoid  fossa. 
The  forearm  is  bent  at  an  angle  varying  from  9U°  to  120°  to  the  anterior 
surface  of  the  humerus,  and  is  well  supinated.  Motion  is  painful  and 
limited.  The  character  of  the  injury  may  be  determined  by  the  absence 
of  the  olecranon  projection,  the  smooth,  bi'oad,  posteri(jr  surface  of  the 
lower  end  of  the  humerus  being  readily  appreciated. 

Treatment. — An  ana>sthetic  is  usually  required.  With  the  forearm 
held  at  about  a  right  angle  to  the  arm,  make  extension  from  the  wrist, 
and  counter-extension  from  the  lower  anterior  surface  of  the  humerus,  in 


Fio.  364.— (Eriohsen.) 


DISLOCATIONS.  329 

order  to  disengage  the  olecranon  process  from  the  coronoid  fossa,  and, 
when  this  is  effected,  make  direct  pressure  downward  upon  the  anterior 
aspect  of  the  forearm,  near  the  elbow.  After  the  bones  .slip  seemingly 
into  position,  careful  examination  should  be  made  to  see  that  the  radius 
is  in  its  proper  relation  to  the  external  condyle,  for  the  ridge  between  the 
two  sigmoid  cavities  of  the  ulna  may  lodge  in  the  groove  between  the 
trochlear  surface  and  the  articular  surface  for  the  head  of  the  radius. 

In  the  outward  lateral  dislocation  the  luxation  is  usually  partial. 
The  cause  is  direct  violence  applied  to  the  inner  aspect  of  the  forearm, 
near  the  joint,  or  to  the  outer  aspect  of  the  humerus,  low  down,  or  to 
force  applied  simultaneously,  in  opposite  directions,  upon  these  two 
surfaces. 

The  diagnosis  will  rest  chiefly  upon  the  increased  prominence  of  the 
inner  condyle,  and  the  difficulty  of  recognizing  the  outer  condyle  by  pal- 
pation. The  angle  at  the  elbow  is  about  120^,  motion  is  wanting,  and  the 
hand  is  pronated.  Reduction  is  best  effected  by  strong  extension  from 
the  forearm,  counter-extension  from  the  humerus,  and  direct  lateral 
pressure  in  the  direction  of  the  displacement. 

Inward  dislocation  is  always  incomplete  (Hamilton).  The  causes  are 
direct  violence  in  the  opposite  direction  to  that  given  for  the  luxation 
outward.  The  internal  condyle  will  be  less  prominent,  the  external  more 
prominent,  the  olecranon  will  be  seen  crowded  over  to  the  inner  aspect 
of  the  joint,  while  the  head  of  the  radius  rests  near  the  middle  of  the 
articular  surface  of  the  humerus.  The  position  of  the  forearm  is  that  of 
flexion.  Reduction  is  difiicult,  and  should  be  effected  in  ether  narcosis. 
Extension  and  counter-extension  should  be  made  in  the  flexed,  position, 
and  the  arm  gradually  brought  out  straight,  while  at  the  same  time  direct 
pressure  is  made,  in  proper  and  opposite  directions,  upon  the  humerus 
and  forearm,  near  the  joint. 

Dislocation  of  both  bones  backward  is  the  most  frequent  form  of  dis- 
placement at  the  elbow.  Incomplete  external  and  incomplete  internal 
luxation  are  next  in  order  of  frequency,  while  the  forward  dislocation  is 
most  infrequent. 

In  the  posterior  variety  the  direction  of  the  force  may  be  such  that  a 
deviation  to  one  or  the  other  side  may  occur.  The  treatment  is  practi- 
cally the  same.  Direct  lateral  pressure  in  the  line  of  the  normal  position 
of  the  bone  may  be  required  in  addition  to  the  mechanism  of  reduction 
above  given.  Partial  anchylosis  is  not  infrequent  after  these  lesions. 
Passive  motion  should  be  begun  within  two  weeks  after  the  injurj^  and 
repeated  daily  if  no  acute  inflammation  is  produced. 

Wrist-Joint. — Dislocations  at  the  carpo-radial  joint  are  very  rare. 
Only  a  few  instances  of  complete  backward  or  forward  luxation  of  the 
carpus  are  on  record.  Lateral  dislocations  are  considered  impossible 
without  fracture  of  the  styloid  process  of  the  radius  or  ulna.  The  two 
principal  displacements  occur  with  about  equal  frequency.  In  the  back- 
ward variety  the  anterior  aspect  of  the  carpus  rests  upon  the  dorsal  rim 
of  the  cancellous  expansion  of  the  radius,  the  reverse  being  true  in  the 
dislocation  forward.     The  anterior  and  posterior  ligaments  are  partially 


330  A  TEXT-BOOK   ON  SURGERY. 

or  completely  ruptured,  and  tlie  annular  ligament,  which  binds  the  ten- 
dons down,  may  be  torn  and  the  tendons  displaced. 

The  cause  of  the  hacliward  displacenit^nt  is  a  fall  on  tlie  back  of  the 
hand,  or  a  blow  upon  the  (lorsum  of  tlu;  radius,  just  above  the  wrist, 
while  the  hand  is  in  extreme  Hexion.  Violence  of  a  similar  character, 
applied  in  tlie  opposite  direction,  will  produce  {\\e  forwarfl  luxation. 

The  didjjuosis  must  be  matle  between  Colles's  fracture  and  disloca- 
tion. In  d/slocaiion  the  deformity  from  the  over-riding  carpus  is  iiiucli 
greater  than  after  fracture.  In  CoUes's  fracture  the  swelling  on  the 
dorsum  of  the  wrist  is  smooth  and  rounded.  When  impaction  has  not 
occurred  crepitus  may  be  obtained. 

Reduction  is  effected  by  extension  and  counter-extension  from  the 
forearm  and  hand,  to  which  direct  pressure  in  the  line  of  displacement 
should  be- added. 

Dislocation  of  the  metacarpal  Ixmes,  at  their  carpal  extremities,  is 
rare.  Luxation  of  the  metacarpal  bone  of  the  thumb  is  most  frequently 
met  with.  The  carpal  end  of  this  bone  may  be  displaced  partially  or 
completely,  in  a  forioarcl  or  backicard  direction.  When  the  end  of  the 
bone  rests  upon  the  dorsum  of  the  trapezius  it  can  be  easily  recognized. 

Extension  and  counter-extension,  with  direct  pressure,  is  usually  suffi- 
cient to  accomplish  reposition.  A  clove-hitch  or  snare  may  be  thrown 
around  the  thumb  to  insure  extension.  Reduction  is  at  times  difficult, 
and  the  history  of  this  accident  is  not  without  a  record  of  failure  both  as 
to  replacement  and  retention  when  replaced. 

In  the  displacement  forward,  on  account  of  the  thickness  of  the  soft 
parts,  the  end  of  the  bone  can  not  be  easily  recognized.  An  unusiud 
depression  may  be  observed  on  the  radial  and  dorsal  aspects  of  the  wrist, 
just  in  front  of  the  os  trapezium. 

Strong  extension  with  counter-extension  is  necessary,  and  to  this 
should  be  added  direct  pressure,  applied  near  the  end  of  the  displaced 
bone. 

Luxation  of  the  remaining  metacarpal  liones  occurs  rarely,  and,  when 
met  with,  the  disjilacement  is  usually  partial,  and  toward  the  dorsum  of 
the  carpus. 

The  phalanges  may  be  dislocated  either  hacJiward  or  forward  at  the 
metacarpal  articulations,  or  at  the  interphalangeal  joints.     The  character 


Fio.  .305.— (After  Hamilton.  I 


of  the  lesion  is  easily  recognized  and  the  reduction  not  difficult.  Exten- 
sion with  a  clove-hitch,  or  with  the  api)aratus  shown  in  Fig.  365,  will 
effect  reduction. 

Hip-Joint. — While  the  head  of  the  femur  may  be  displaced  from  the 
cotyloid  cavity  in  any  direction,  it  is  customary  to  consider. /"o^r  distinct 


DISLOCATIONS. 


331 


luxations:  (1)  Ujwn  tlie  dorsum  il'il ;  (2)  into  the  ischiatic  notch;  (3) 
into  the  obturator  foramen ;  (4)  upon  the  os  pubis.  Practically  these 
lesions  occur  in  each  of  the  quadrants  of  a  cu'cle,  the  center  of  which  is 
the  center  of  the  acetabulum. 

As  shown  in  Fig.  366,  about  50  per  cent  of  all  luxations  at  the  hip 
occur  in  the  iliac  quadrant,  30  per  cent  in  the  ischiatic,  11  per  cent  in  the 
obturator,  and  7  per  cent  in  the  pubic.    Two  per  cent  occur  beyond  these 
regions.      Cases  are  on  record 
where  the  head  of  the  bone  was 
lodged   on  the  tuber  ischii,   in 
the  perinfeum,  and  just  beneath 
the   anterior- superior  spine   of 
the  ilium. 

The  capsule  is  usually  torn 
at  its  inferior  and  posterior  sur- 
face. It  may  be  a  slit  or  tear 
in  the  long  axis  of  the  liga- 
ment, or  frequently  a  broad 
rapture  occurs  along  the  edge 
of  the  cotyloid  cavity.  The 
ligamentum  teres  (when  pres- 
ent) is  always  torn.  The  ilio- 
femoral (or  Y)  ligament  is  very 
rarely  completely  ruptured.  The 
injury  to  the  muscles  and  sur- 
rounding  structures   is   always 

severe,  and  varies  in  proportion  to  the  degree  of  violence  which  caused 
the  luxation,  together  with  the  particular  direction  of  the  displace- 
ment. 

In  the  displacement  upon  the  dorsum  ilii  the  glutei  muscles  may  be 
lacerated,  bruised,  or  lifted  from  the  ilium  by  the  head  of  the  bone,  but 
not  by  tension  on  their  tendons,  for,  with  the  exception  of  the  lower 
fibers  of  the  maximus,  their  axes  are  slightly  shortened  in  the  new  posi- 
tion. The  obturator  intermis,  externus,  gemelli,  and  quadratus  femoris 
are  greatly  stretched,  or  torn  entirely  loose.  The  pyriformis  is  not  so 
apt  to  suffer.  The  pectineus,  iliacus,  and  psoas  are  carried  upward  and 
outward.  When  the  head  of  the  bone  is  projected  into  the  ischiatic 
notch,  the  conditions  as  to  the  muscles  are  practically  unchanged.  The 
sciatic  nerve  and  vessels  are  pressed  upon  and  may  be  contused  or  lacer- 
ated. In  the  displacement  upon  the  pubes  the  psoas  and  iliacus  may  be 
injured,  while  the  femoral  vessels  and  anterior  crural  nerve  are  more  or 
less  pressed  upon.  When  the  head  of  the  bone  is  lodged  in  the  obturator 
foramen,  the  obturator  externus  muscle  and  the  obturator  vessels  and 
nerves  are  more  or  less  contused,  while  the  glutei  and  the  remaining 
external  rotators  are  put  upon  the  stretch. 

Causes. — Dislocations  at  the  hip  may  be  congenital,  pathological,  or 
traumatic  in  cause. 

Congenital  luxations,  rare  in  occurrence,  are  the  result  of  interference 


Fig.  306. — Showing  the  proporticn  of  displacement  in  the 
four  quadrants  of  a  circle  about  the  acetabulum. 


332 


A  TEXT-BOOK   ON   SURGERY. 


with  iiDrmal  development.  Failure  to  complete  the  process  of  ossification 
in  the  three  bones  which  compose  the  acetabulum  leaves  a  soft  and  fibro- 
cartila<iinous  cup  or  sac,  through  whicli,  when  the  weight  of  tlie  l)ody  is 
sufficient,  the  head  of  the  femur  is  more  or  less  completely  disphiced  into 
the  pelvic  cavity.  Absence  of  the  ligamentum  teres  is  not  alone  sufficient 
to  account  for  displacement  when  the  bones,  capsule,  and  muscles  are 
normal,  for  it  is  not  infrequently  absent  in  cases  which  have  never  suf- 
fered a  luxation.  Moreover,  the  majority  of  cases  in  which  this  ligament 
has  been  ruptured  by  one  luxation  do  not  suffer  a  second  disi)lacempnt. 
An  abnormally  long,  loose,  or  relaxed  capsule  will  lead  to  sub-luxation 
or  displacement  without  rupture  of  the  capsule.  Failure  of  development 
from  tlie  cervical  epiphysis  is  another  cause  of  congenital  dislocation  at 
the  hip. 

Pathological  dislocations  are  caused  by  chronic  arthritis.  Tlie  bones 
are  moi-e  or  less  destroyed,  and  the  capsule  breaks  down,  permitting  dis- 
location of  the  head  of  the  bone  as  a  result  of  muscular  action  or  sliglit 

violence. 

Traumatic  luxations  are  direct  or  indi- 
rect. The  most  frequent  cause  is  a  fall 
from  a  height  or  from  a  carriage  in  mo- 
tion, the  person  striking  upon  the  foot  or 
knee,  with  the  thigh  carried  in  such  a  di- 
rection that  its  axis  is  at  a  considerable 
angle  to  that  of  the  spinal  column. 

Anatomically  considered,  the  most  fa- 
vorable position  for  the  two  posterior,  and 
by  far  the  most  frequent  displacements,  is 
when  the  thigh  is  flexed  at  about  an  angle 
of  9U°  to  the  axis  of  the  body.  If  fhe 
thigh  be  adducted,  the  tendency  is  to  rupt- 
ure the  capsule  on  its  posterior-inferior 
surface,  with  escape  of  the  head  on  to  the 
dorsum  ilu,  or  into  the  isch/'atic  notch. 
When  in  a  position  of  abduction,  the  rupt- 
ure is  likely  to  occur  on  the  lower  anterior 
aspect  of  the  capsule. 

A  fall  directly  upon  the  trochanter,  with 
the  thigh  in  adduction  or  abduction,  with 
extreme  outward  or  inward  rotation,  is  apt 
to  produce  rupture  of  the  capsule  and  lux- 
ation. 

Symptoms.  —  In  dislocation  upon  the 
dorsum  ilii,  with  the  patient  standing  erect 
upon  the  uninjured  extremity,  the  trochan- 
ter of  the  displaced  femur  will  be  nearer 
the  anterior-superior  spine  of  the  ilium  than 
that  of  the  opposite  side  ;  the  thigh  is  slightly  flexed  upon  the  abdomen, 
adducted,  and  rotated  inward.    The  head  of  the  bone  may  be  appreciated 


Fio.  367.— Position  of  extremity  in  dis- 
location of  tlK^  head  of  the  femur  upon 
the  dorsum  ilii.     (After  Hamilton.) 


DISLOCATIONS. 


333 


in  the  new  position.  The  shortening  is  from  one  to  two  inches,  and  in 
the  vast  majority  of  cases  the  great  toe  of  the  injured  side  is  directed  to 
or  rests  upon  the  instep  of  the  opposite  foot,  while  the  knee  of  the  lux- 
ated side  is  in  front  of,  and  slightly  above,  its  fellow  (Fig.  367).  Muscu- 
lar rigidity  and  fixation  are  extreme.  In  very  exceptional  cases  there  is 
eversion  of  the  foot,  with  slight  abduction,  which  Prof.  Bigelow  holds  to 
be  due  to  extensive  and  unusual  laceration  of  the  ilio-femoral  ligament. 

When  the  head  of  the  bone  is  lodged  in  the  iscMatic  notc?i,  the  gen- 
eral characters  of  the  deformity  are  the  same,  yet  not  so  well  marked. 
The  degrees  of  flexion  and  adduction  are  less  extreme,  the  trochanter  is 
less  prominent,  and  there  is  not  so 
much  shortening. 

In  the  tJti/roid  displacement  the 


FiQ.  3G8. — Position  of  extremity  in   dislociition   of      Fio.  SBO. — Position  of  extremity  in  dislocation  of  the 
the  liead  of  tlie  femur  into  tlie  tliyroid  foramen.  head  of  the  lemur  upon  the'pubes.     (Atler  Ham- 

(At^er  Hamilton.)  ilton.) 

extremity  is  increased  in  length,  and  the  thigh  is  abducted  and  slightly 
flexed  upon  the  abdomen.  The  toes  may  be  turned  slightly  in  or  out, 
although  they  usually  point  to  the  front.  The  hip  is  less  prominent  than 
normal.  The  head  of  the  femur  may  at  times  be  recognized  in  the  new 
position,  although,  on  account  of  the  tense  condition  of  the  adductor 
muscles,  this  is  in  some  mstances  impossible  (Fig.  368). 


334 


A  TEXT-BOOK   OX   SURGERY. 


^VheIl  the  dislocation  occurs  on  the  pubes  there  is  abduction,  slight 
flexion,  and  slight  outward  rotation.  The  foot  is  can-ied  away  from 
that  of  the  sound  side,  and  the  toes  are  pointed  outward.  The  chief 
diagnostic  feature  of  this  displacement  is  the  presence  of  the  head  of  the 
bone  at  Poupart's  ligament  (Fig.  369). 

The  differential  diagnosis  is  between  muscular  spasm  or  rigidity  and 
fracture. 

Spasm  or  rigidity  of  the  muscles  about  the  hip  may  occur  as  a  re- 
sult of  an  acute  or  subacute  inflammatory  process  in  the  joint,  or  in 
the  periarticular  tissues,  or  in  certain  cases  of  ostitis  of  the  lumbar 
vertebrae,  sacrum,  or  ilium,  in  the  neighborhood  of  the  psoas  and  llia- 
cus  muscles.  This  condition  of  partial  immobility  may  be  differentiated 
from  that  of  dislocation  by  the  absence  of  the  sJiortenhiff,  which  is 
present  in  the  displacement  on  the  dorsum  1111  and  Into  the  Ischiatlc 
notch,  the  lengthening  in  the  thyroid  luxation,  while  the  head  of  the 
bone  on  the  pubes  will  deteiTnlne  the  character  of  this  lesion.  The 
absence  of  the  characteristic  defoniuty  of  each  of  these  forms  (jf  dislo- 
cation will  determine  the  diagnosis  of  muscular  spasm  or  rigidity.  The 
symptoms  of  fracture  near  the  hip  have  been  given.  Shortening,  pre- 
ternatwral  niubllity,  and  crepitus  are  to  be  chiefly  relied  upon  in  differ- 
entiation. 

Reduction — Dislocation  on  the  Dorsum  Ilii — Bigeloic\s  Mdliod. — 
In  complete  ether  narcosis,  place  the  patient  upon  a  strong,  low  table,  or 
upon  the  floor,  in  the  dorsal  decubitus.  Grasp  the  leg  of  the  dislocated 
side,  just  above  the  ankle,  with  one  hand,  and  near  the  knee  with  the 

other,  flex  the  leg  on  the  thigh,  and  the 
thigh  on  the  abdomen,  to  nearly  an  angle 
of  90°  \nth  the  surface  of  the  floor,  ad- 
duct  the  thigh  until  the  knee  of  this  side 
is  carded  to  about  the  middle  of  the  sound 
thigh,  and  then  cause  the  knee  to  describe 
a  circle  outward  and  downward  until  the 
leg  is  brought  to  the  floor  in  its  normal 
position  (Fig.  370).  If  the  luxation  is  not 
reduced  the  manoeuvre  should  be  careful- 
ly repeated.  This  method  of  reduction 
by  manipulation  is  based  upon  the  resist- 
ance to  reduction  which  is  made  by  the 
illo-femoral  ligament  (when  this  is  not 
torn). 

Tlie  normal  position  of  this  ligament 
is  shown  in  Fig.  371,  and  its  relaxation 
by  flexing  the  dislocated  thigh  upon  the 
abdomen  is  shown  in  Fig.  372 ;  and  it  Is 
readily  seen  that  if,  with  the  thigh  in  this 
position,  abduction,  with  outward  rota- 
tion, is  practiced,  the  head  of  the  1x)ne  will  be  lifted  over  the  margin  of 
the  acetabulum  and  can-led  in  the  diiectlon  of  the  socket. 


Fio.  370. — Eeducrion  of  dislocation  on  the 
dorsum  ilii  by  manipulation.  (After 
Bigelow.; 


DISLOCATIONS. 


335 


Fig. 


372. — Relaxation  oi    '.L.  'iiunral  licrament  by 

fie.vion  and  ndductiun  of  tiiiijli.     (Bigeloiv.) 


Fig.  371. — The  ilio-fomoral  or  Y  ligament. 
{Bigelow.) 


Crosby's  Metliod* — Place  tlie  pa- 
tient on  the  floor,  in  the  dorsal  decu- 
bitus. Flex  both  legs  on  the  thigh, 
and  the  thighs  on  the  abdomen,  and, 
with  the  arms  locked  underneath  the 
knees,  raise  the  patient  from  the 
floor  so  that  the  body  will  rest  only  on  tlie  neck  and  shoulders.  If, 
after  suspension  lasting  two  or  three  minutes,  reduction  is  not  accom- 
plished, the  patient  should  be 
swayed  from  side  to  side,  thus 
adding  alternately  slight  abduc- 
tion and  adduction  to  the  exten- 
sion. While  the  displacement  may 
be  overcome  without  angesthesia, 
it  is  much  more  easily  and  surely 
effected  with  it. 

The  same  result  may  be  accom- 
I)lished  by  employing  vertical  ex- 
tension in  the  manner  recommend- 
ed by  Bigelow  and  shown  in  Fig. 
873. 

Hamilton's  Iletliod.—The  pa- 
tient is  in  the  dorsal  decubitus, 
and  the  limb  is  grasped  as  in  Bige- 
low's  method.  "  Flexing  the  leg 
on  the  thigh,  the  knee  is  to  be 
carefully  lifted  toward  the  face  of 
the  patient,   until  it  meets  with     ^ 

„„.,„,    „      •    i    _  -i.  ^    ,1  1  iiG.  373. — Reduction  of  dislocation  on  tlie  dorsum  Uii 

some  resistance  ;  it  must  then  be  by  vertical  extension.   (Bigoiow.) 


*  Tills  method  was  introdaced  by  the  late  Prof.  A.  B.  Crosby. 


33(i 


A  TEXT-BOOK   ON  SURGERY. 


moved  outward  and 
slightly  rotated  in  the 
same  direction,  until  re- 
sistance is  again  en- 
countered, when  it  must 
be  brought  downward 
again  to  the  bed." 

The  older  method  of 
violent  extension,  by 
means  of  blocks  and 
pulleys,  should  not  be 
employed,  unless  all 
other  means  have  failed. 

Reduction  of  Dis- 
locations into  the  Is- 
chiatic  Notch. — In  this 
luxation  the  mechan- 
ism of  reduction  is  prac- 
tically the  same  as  for 
the  preceding  disj^lace- 
ment.     One  point  must 

Fio.  374. — Cooper's  metbo'l  of  extension  and   counter-extension  in       ,  ..11  "      .f 

reduction  oi' (lislocutiou  into  tlie  isoliiatic  notch.     (Hamilton.)  Oe      guartlecl     against  — 

the  danger  that,  when 
the  head  of  the  femur  reaches  the  margin  of  the  acetabulum,  it  may  be 
deflected  below  the  rent  in  the  capsule,  and  lodge  in  the  thyroid  foramen. 

If  extension  and  counter-extension  after  the  older  method  (Astley 
Cooper's)  be  necessitated,  the  pelvis  should  be  fixed  by  a  sheet  folded 
and  passed  through  the  peri- 
njBum  and  over  the  groin,  and 
extension  made  from  above  the 
knee,  with  the  thigh  flexed  al- 
most to  an  angle  of  90°  with 
the  abdomen,  and  adducted  un- 
til the  knee  is  carried  in  front 
of  the  opposite  thigh  (Fig.  374). 

Reduction  of  Dislocations  in 
the  Thyroid  Foramen — Method 
of  Bigelow. — Place  the  patient 
upon  the  floor,  in  the  dorsal  de- 
cubitus, flex  the  leg  on  the  thigh, 
and  the  thigh  on  the  abdomen, 
making,  at  the  .same  time,  slight 
abduction.  Then  rotate  the  fe- 
mur inward,  adduct,  and  carry 
the  knee  to  the  floor. 

The  older  method  involved 
extension  in  a  lateral  direction,        ,..,.,.    t,  ,     •      ,.,.,..       ,     ,     ■, 

.        rio.  37o. — Keduction  or  dislocation  into  tlie  thyroid 

by  means  oi  a  sheet  folded  and  toramen.   (Bigeiow.) 


DISLOCATIONS. 


337 


Fig.  376. — Showing  the  relation  of  the  ilio-femoral 
ligament  in  dislocation  of  the  head  of  the  fe- 
mur into  the  thyroid  foramen.     (Bigelow.) 


l^iilleys  can  not  be  had,  the  sheet 
should  be  tied  into  a  loop 
and  laid  over  the  shoulder 
of  the  operator. 

Reduction  of  Dislo- 
cations iipon  the  Pubes 
— Ha  m  ilton\s  Meth  od.  — 
When  the  head  of  the 
bone  is  lodged  well  over 
the  pelvic  rim  the  thigh 
should  be  abducted  and 
rotated  outward,  in  order 
that  the  head  may  be 
thus  lifted  over  the  pu- 
l)es,  and  then  flexed  upon 
the  body,  addiicted,  and 
In-ought  down.  Rotation 
outward  should  cease  as 
soon  as  the  head  of  the 
bone  has  risen  above  the 
pubes.  When  the  head 
has  not  passed  above  the 
rim  of  the  pubes,  out- 
ward rotation  is  not  called 
for. 

22 


Fi3.  377- — Showing  how  flexion  of  the  thigh  on  the 
abdomen  relaxes  the  ilio  femoral  ligament  in 
dislocation  into  the  thyroid  foramen.   (Bigelow.) 

passed  around  the  inner  surface  of 
the  thigh,  while  the  jielvis  was 
lixed  by  a  sheet  passed  around 
this  part  of  the  body,  and  npon 
which  traction  was  employed  in  an 
opposite  direction  (Fig.  378).  If 
which  is  carried  around  the  thigh 


Fio.  378.— < 


Cooper's  method  of  reducing  dislocation  into  the  thy 
roid  foramen.     (Hiunilton.) 


338  A  TEXT-BOOK  ON  SURGERY. 

If  in  this  manoeuvre  the  bone  slips  into  the  thyroid  foramen,  the 
manipulation  given  for  this  hixation  should  be  practiced. 

Ihi  Extension  and  Counfer-Ki-frns/on—Nani/Ifon's  3L't7iofl.—'P\nce 
the  patient  ux)on  the  edge  of  a  bed  or  table,  so  that  the  injured  limb  may 


Fio.  379. — Keduction  of  ilisloeation  upon  the  pubes  by  extension  and  counter-extension.     (Hamilton.) 

fall  slightly  over  the  edge.  Extension  is  made  from  the  thigh,  and 
counter-extension  from  the  perinjeum  and  groin,  in  the  direction  indi- 
cated in  Fig.  379. 

The  after-treatment  of  hip-luxation  involves  fixation  of  the  muscles 
about  the  joint  for  from  two  to  six  weeks.  A  gutta-percha,  heavy 
pasteboard,  or  leather  splint,  molded  to  the  side  of  the  pelvis,  thigh, 
and  down  to  the  ankle,  applied  upon  a  thin  layer  of  absorbent  cot- 
ton, and  held  in  place  by  a  leg-,  thigh-,  and  spica-bandage,  should  be 
employed. 

The  prognosis  as  to  rapid  restoration  of  function  is  not  always  favor- 
able. The  injury  to  the  capsule,  and  more  especially  to  the  muscles 
around  the  joint,  may  lead  to  an  impairment  of  the  hip,  more  or  less 
permanent.  In  permanent  luxations,  in  some  instances,  a  fair  degree  of 
mobility  may  be  developed.  Reduction  has  been  successfully  performed 
as  late  as  four  and  six  months  after  the  injury. 

The  treatment  of  congenital  dislocations  of  the  hip,  and  of  patliologi- 
cal  luxations,  will  be  given  later. 

Dislocations  at  the  Knee — The  Tibia  from  the  Femur. — Displace- 
ment of  the  femoral  end  of  the  tibia  may  occur  as  a  result  of  congenital 
malformation,  disease,  or  accident. 

Congenital  luxation  is  rare,  and  is  usually  jrartial.  As  a  rule,  the 
tibia  is  displaced  forward,  although  the  opposite  condition  may  pi-evail. 
Al)sence  of  the  patella  has  been  observed  in  several  of  these  cases. 

Pathological  dislocations  will  be  given  under  the  head  of  diseases  of 
this  joint. 

Traumatic  luxation  at  the  knee  is  comparatively  rare.  The  tibia 
may  be  completely  or  partially  displaced,  and  in  any  direction.  Partial 
dislocation  is  the  rule.  Complete  luxation  is  apt  to  be  complicated  with 
a  wound.  A  compound  dislocation  usually  occurs  forward  or  backward. 
The  cause  is  direct  violence.  A  blow  upon  the  anterior  aspect  of  the 
tibia,  near  the  joint,  or  the  j)osterior-inferior  portion  of  the  femur,  may 


DISLOCATIONS.  339 

cause  a  baclcicard  displacement  of  the  tibia,  while  violence  from  opposite 
directions  may  produce  a  forward  dislocation.  The  same  force  applied 
laterally  may  also  produce  the  lateral  displacements.  A  faA-oral)le  condi- 
tion for  luxation  is  the  application  of  violence  when  the  leg  is  in  extreme 
flexion.  A  sudden  twisting  or  wrenching  of  the  femur  upon  the  tibia 
when  the  foot  is  so  caught  that  rotation  on  the  heel  is  impossible,  is 
favorable  to  rupture  of  the  ligaments,  and  lateral  or  oblique  incomi)lete 
luxation. 

The  symptoms  of  dislocation  at  the  knee  are  usually  clear.  In  the 
backward  variety  the  antero-posterior  diameter  of  the  knee  is  increased, 
the  tibia  projects  into  the  popliteal  space,  and  the  condyles  of  the  femur 
are  unusually  prominent.  In  the  forward  variety  the  antero-posterior 
measurements  are  also  increa.sed,  the  anterior  edges  of  the  tibia  are  easily 
detected  in  the  advanced  position  of  this  bone,  while  the  condyles  of  the 
femur  are  iinusually  prominent  posteriorly.  The  tibia  may  be  rotated 
upon  its  axis.  In  the  lateral  displacements  the  condyle  of  the  femur  is 
recognized  as  projecting  on  one  side,  while  the  flat  end  of  the  tibia  is  felt 
on  the  opposite  side.  The  transverse  diameter  of  the  joint  is  increased 
in  proportion  to-  the  degree  of  displacement,  which  is,  however,  rarely 
complete. 

Treatment. — Reduction  is  readily  effected  by  extension  and  counter- 
extension,  with  direct  pressure  and  counter-pressure  in  the  projier  direc- 
tions. Once  reduced,  fixation  should  be  secured  by  Buck's  extension, 
vsath  sand-bags  applied  to  the  limb,  or  an  investing  sjilint  should  be 
emyjloyed. 

The  prognosis  after  this  injury  is  unfavorable.  The  function  of  the 
joint  is  rarely  fully  restored.  The  question  of  amputation  after  disloca- 
tions of  the  knee,  where  there  is  extensive  injury  of  the  surrounding 
sti'uctures,  is  one  of  great  importance.  Shock  is  more  profound  in  this 
luxation  than  in  dislocation  at  any  other  joint.  A  primary  amputation 
will  rarely  be  justified  except  after  laceration  of  the  popliteal  vessels.  All 
antiseptic  measures  should  be  employed,  and  amputation  only  advised 
after  every  effort  consistent  with  the  safety  of  the  patient's  life  has  been 
made. 

Dislocation  of  tlie  Patella. — This  bone  may  be  displaced  by  muscular 
action,  without  the  aid  of  external  violence,  or  by  an  injury  alone.  When 
the  ligamentum  patellse  is  ruptured,  it  is  carried  iipward  for  a  varying 
distance  by  the  contraction  of  the  quadriceps.  It  can  only  be  displaced 
doicnward  by  a  blow  received  upon  its  upjjer  margin  sufficient  to  tear  it 
loose  from  its  muscular  attachments.  Dislocation  outward  is  the  more 
frequent  variety,  and  occurs  as  a  result  of  muscular  contraction  and  from 
violence.  Displacement  inioard  is  the  result  of  a  blow  received  upon  the 
outer  margin  of  the  bone.  In  the  lateral  dislocations,  in  rare  instances, 
the  patella  is  turned  obliquely  on  its  edge,  or  it  may  possibly  be  com- 
pletely inverted. 

The  sf/mptoins  of  these  various  luxations  are  unmistakable,  and  the 
reduction,  by  relaxing  the  quadriceps  and  pressure,  not  difficult. 

The  after-treatment  is  directed  to  the  i)reventiun  of  recunvnce. 


340  A  TEXT-BOOK   ON  SURGERY. 

Dislocations  at  the  AnMe-Joint. — Dislocations  at  tlie  tibio-tarsal 
articulation  may  occur  in  four  directions,  viz.,  forward.,  baclcward,  in- 
toard,  and  outward.  In  the  last  two  forms  fracture  of  one  or  the  other 
malleolus  is  apt  to  occiir. 

Dislocation  of  the  tibia  inward  is  caused  by  a  fall  ujion  the  foot  at  a 
time  when  it  is  turned  outward,  the  body-weight  being  brought  to  bear 
upon  the  inner  aspect  of  the  heel  and  great  toe.  Tliis  foiTn  of  sprain  is 
frequently  caused  by  leaping  from  a  wagon  or  car  in  motion.  It  may 
also  result  from  a  heavy  blow  upon  the  fibular  side  of  the  leg,  near  the 
ankle,  when  the  foot  is  solidly  fixed  against  the  ground.  The  displace- 
ment is  usually  partial.     A  complete  luxation  is  apt  to  be  compound. 

The  symj)toins  of  inward  dislocation  are  the  great  prominence  of  the 
inner  nuilleolus  and  the  peculiar  twist  of  the  foot,  so  that  the  inner  side 
of  the  heel  and  the  great  toe  rest  on  the  floor  while  the  sole  looks  ob- 
liquely outward  and  upward.  The  only  displacement  it  may  be  mistaken 
for  is  that  of  the  astragalus  from  the  os  cah'is. 

The  treatment  is  to  bring  the  foot  into  the  normal  position  by  pressure 
and  counter-j^ressure,  and  fix  it  with  a  splint  and  bandage.  On  account  of 
the  great  swelling  which  is  likely  to  occur,  an  immovable  dressing  should 
not  be  applied  until  the  acute  symptoms  of  inflammation  have  subsided. 

The  symptoms  of  outward  displacement  are  the  reverse  of  the  inward, 
and  can  without  difficulty  be  recognized.  Displacement  of  the  tendons 
of  the  long  and  short  peronei  muscles,  from  theii-  sheaths  behind  the 
external  malleohas,  is  likely  to  occur  in  this  accident.  After  reduction 
at  the  Joint  these  should  bs  pushed  into  place,  and  an  effort  (rarely  suc- 
cessful) made  to  hold  them  in  position  by  a  compress  and  bandage,  ap- 
plied before  the  splint  for  the  luxation  is  adjusted. 

Forward  dislocation  may  occur  as  the  result  of  a  blow  upon  the  back 
of  the  leg,  near  the  ankle,  while  the  foot  is  firmly  placed  upon  the  ground  ; 
by  falling  forward  with  great  violence,  when  the  momentum  of  the  body 
is  suddenly  arrested  by  the  foot  striking  against  the  ground  ;  or  by  fall- 
ing backward,  with  the  foot  so  fixed  that  great  and  unusual  extension  of 
the  tarsus  takes  place. 

The  symptoms  are  unnatural  prominence  of  the  heel,  shortening  of  the 
distance  between  the  toes  and  the  front  of  the  tibia,  on  the  displaced  side. 

Reduction. — Place  a  clove-hitch  around  the  heel  and  instej)  for  exten- 
sion, and  make  counter-extension  from  the  thigh.  Flex  the  leg  so  as  to 
relax  the  sural  muscles,  and  make  forcible  extension  from  the  foot.  As 
soon  as  the  extension  is  well  begun  the  operator  places  his  foot  against 
the  front  of  the  patient's  tibia,  just  above  the  ankle,  and  puUs  forward 
on  the  foot,  at  the  same  time  flexing  it  on  the  tibia. 

Backward  displacement  is  caused  by  violence  applied  in  a  direction 
opposite  to  that  which  produces  the/brwarrZ  luxation,  and  the  symptoms 
are  exactly  the  reverse. 

The  treatment  demands  reduction  by  extension  and  counter-extension, 
and  direct  pressure. 

Dislocations  at  the  ankle  are  often  complicated  with  fracture,  or  may 
be  compound.     In  any  fonn  of  injury  an  effort  should  be  made  to  save 


DISLOCATIONS.  341 

the  foot  and  joint.  The  ankle  is  exceedingly  tolerant  of  surgical  inter- 
ference, and,  with  strict  cleanliness  and  antisepsis,  amputation  on  account 
of  complicated  or  compound  dislocation  will  lie  rarely  necessary. 

The  libula  may  be  displaced  from  its  articulation  with  the  tibia  at  its 
tipper  or  lower  end.  At  the  upper  end  it  is  usually  luxated  forward,  as 
a  result  of  direct  violence  fi-om  behind,  although  it  is  possible  to  have  the 
reverse  occur.  The  bone  will  be  felt  in  the  abnormal  and  anterior  posi- 
tion, and  may  be  pushed  directly  back  into  place.  In  the  backward  dis- 
placement the  biceps  muscle  may  produce  the  luxation,  or  it  maybe  from 
violence  aj^plied  from  the  front.  Strong  and  continued  pressure  must  be 
employed  to  retain  the  bone  in  position  until  adhesions  occur.  During 
the  treatment  the  leg  should  be  flexed  on  the  thigh  in  order  to  relax  the 
biceps. 

At  the  lower  end  dislocation  of  the  fibula  alone,  without  the  tibia,  is 
exceedingly  rare.  Anatomically,  it  may  occur  in  both  dii-ections.  Re- 
duction may  be  effected  by  direct  pressure.  The  fibula  may  be  displaced 
outward  from  the  tibia  by  the  astragalus  being  driven  upward  between 
these  bones. 

Dislocations  of  the  Bones  of  the  Tarsus. — The  astrar/aliis  may  be 
partially  or  completely  dislocated  fonvard,  backward,  outward,  or  in- 
ward. The  luxation  is  usually  incomplete.  On  account  of  the  great 
violence  necessary  to  its  production  it  not  infrequently  is  compound,  or 
complicated  with  a  fracture.  Violence  of  the  same  character  as  that 
which  produces  displacement  of  the  tibia  will  cause  dislocation  of  the 
astragalus. 

Treatment. — Luxation  of  the  astragalus  is  a  serious  accident.  The 
efforts  at  reduction  do  not  always  succeed,  and,  even  when  reduction  is 
effected,  the  injury  to  the  joint  may  be  such  that  loss  of  function  results. 
Direct  pressure  aud  counter-pressure,  while  the  patient  is  jirofoundly 
anaesthetized,  offer  the  best  means  of  successful  reduction.  Displace- 
ments of  the  metatarsal  bones  and  phalanges  of  the  toes  are  treated  in 
the  same  general  way  as  described  for  similar  lesions  of  the  hand. 

The  VertebriB. — Dislocation  may  occur  at  any  articular  surface  of  the 
vertebral  column.  The  accident  is  always  serious,  the  gravity  being  pro- 
portionate to  the  degree  of  displacement  and  the  injury  to  the  cord  and 
nerves. 

Luxations  are  more  common  in  the  cervical  region.  One  or  both 
articular  processes  may  be  displaced  forward  or  backward  upon  the  ver- 
tebra below.  In  the  unilateral  displacement  the  fibro-cartilage  between 
the  bodies  is  only  slightly  involved,  and,  while  there  is  pressure  upon 
the  nerves  passing  out  of  the  intervertebral  foramen,  there  is  no  pressure 
upon  the  cord.  In  the  bilateral  form  the  cartilage  is  torn,  the  body  more 
or  less  involved  in  the  luxation,  and  the  cord  compressed. 

The  causes  are  muscular  contraction,  or  violent  twisting  of  the  neck 
by  accident. 

The  symptoms  of  unilateral  displacement  are  pain — which  may  be 
referred  to  the  distribution  of  the  nerves  ixissing  through  the  interverte- 
bral foramen  involved — at  the  seat  of  luxation  and  rotation  of  the  head. 


342  A  TKXT-BOOK  ON  SURGERY. 

in  a  forward  dislocation,  so  that  the  chin  points  to  the  side  opposite  to 
that  upon  which  the  injury  exists.  When  the  luxation  is  backward,  the 
face  is  turned  toward  tlie  seat  of  injury. 

In  the  case  of  a  young  lady  which  came  under  my  observation,  the 
right  articular  process  of  the  fourth  cervical  vertebra  vpas  displaced  for- 
vvard  by  sudden  and  violent  niuscular  contraction.  Pain  was  acute  at 
the  seat  of  luxation,  and  numbness  down  the  right  arm  indicated  com- 
pression of  some  of  the  filaments  forming  the  brachial  plexus.  Reduction 
was  effected  as  follows  :  The  patient  being  seated  in  a  chair,  the  shoul- 
ders were  held  immovable  and  the  head  further  rotated  to  the  left ;  then 
strong  extension  was  made  by  lifting  the  patient  from  under  the  chin 
and  occiput,  at  the  same  time  carrying  the  head  back  to  the  right.  Relief 
was  immediate  and  pennanent. 

In  bihiteral  luxation  careful  extension  and  du-ect  pressure  and  counter- 
pressure  should  be  practiced. 

Dislocation  of  the  condyles  of  the  occipital  l)one  from  the  atlas  is 
probably  always  fatal.  Luxation  at  the  atlo-axoid  joint,  with  fracture 
of  the  odontoid,  is  also  fatal. 

Jiibs. — The  ribs  may  be  displaced  from  their  vertebral  articulations. 
The  cause  is  direct  violence,  and  the  displacement  usually  forward.  The 
true  ribs  may  be  dislocated  at  the  junction  of  these  organs  with  their 
cartilages,  near  the  sternum.  The  treatment  for  these  luxations  is  the 
same  as  for  fracture. 

Diseases  of  the  Joints  in  General. 

The  simislest  form  of  inflammation  in  a  Joint  is  that  of  the  synovial 
membrane  with  which  it  is  lined,  or  sz/norifis.  A  similar  condition  of 
the  sheaths  of  the  tendons  of  certain  muscles  is  known  as  tJiecitis. 

When  the  ligaments  of  a  joint  become  involved  in  the  inflammatory 
process  the  condition  is  known  as  syndesmitis ;   when  all  the  struct- 
ures of   the  articulation — as  bone,  cartilage,  ligaments,  synovial  mem 
branes,  etc. — are  involved,  it  is  an  arthritis,  or,  as  it  is  sometimes  called, 
osteo-arthritis. 

Synovitis  may  be  circumscribed  or  general.  It  may  precede  or  follow 
a  syndesmitis.  If  the  process  of  inflammation  in  the  lining  membrane  is 
not  very  mild,  lasting  only  a  few  hours,  it  must  of  necessity  involve  the 
ligaments  upon  which  its  basement-substance  rests.  On  the  other  hand, 
a  peri-arthritis  which  invades  the  ligamentous  structures  of  a  joint  will 
also  produce  a  synovitis. 

The  pi'ocess  of  inflammation  in  sjTiovitis  is  primarily  confined  to  the 
joint  capsule,  since  the  lining  membrane  is  not  reflected  on  to  the  articu- 
lar cartilaginous  surfaces.  Hyper^emia  and  dilatation  of  the  capillaries 
in  the  basement  membrane  occurs,  followed  by  escape  of  leucocytes  into 
the  inter-capillary  spaces  and  into  the  capsule,  proliferation  of  the  normal 
epithelia,  and  general  effusion  into  the  cavity  of  the  joint. 

The  synovial  fluid  is  increased  in  quantity,  richer  in  cell-elements  than 
nonnal,  and  may  be  discolored  by  the  esca^je  of  red  blood-corpuscles  or 


DISEASES  OF  THE  JOINTS.  343 

free  hsematin.  The  result  of  this  process  is  distention  of  the  capsule  and 
communicating  bursse,  infiltration  of  the  basement  membrane  with  em- 
bryonic cells,  which  are  the  common  product  of  all  the  proliferating  cell- 
elements  in  the  tissues  involved. 

SynoLHtis  may  terminate  in  various  ways.  If  the  process  is  acute  yet 
mild,  and  all  the  conditions  of  the  individual  tissues  favorable  to  rapid 
repair,  resolution  may  occur  without  invasion  of  the  ligaments,  cartilages, 
or  bones.  The  escaped  corpuscular  elements  undergo  fatty  metamor- 
phosis, together  with  those  of  the  embryonic  tissue,  and  these  elements, 
with  the  excessive  fluid  in  the  capsule,  are_  absorbed.  The  functions  of 
the  joint  are  soon  restored. 

Under  less  favorable  conditions  the  acute  process  may  pass  into  a  sub- 
acute and  chronic  synovitis ;  the  embryonic  granulation-tissue  remains, 
the  normal  epithelial  lining  disappears,  giving  way  to  a  dirty  fungus-like 
granulation-tissue,  which  thickens  the  entire  capsule  and  projects  on  all 
sides  into  the  cavity  of  the  joint.  The  ligaments  may  soften  and  ulti- 
mately break  down,  the  cartilages  become  eroded,  or  a  periostitis  and 
ostitis  may  be  precipitated  by  invasion  of  the  bone,  from  the  point  of 
junction  between  the  synovial  membrane  and  the  osseous  tissue — a  true 
aitJiritls. 

The  causes  of  synovitis  are  predisposing  and  direct.  It  may  be  said 
that  any  dyscrasia  (which  in  itself  indicates  a  low  order  of  tissue-nutri- 
tion) encourages  the  development  of  a  synovitis,  and,  once  inaugurated, 
feebly  resists  its  progress.  Tuberculosis,  syphUis,  gout,  rheumatism,  the 
eruptive  fevers,  traumatic  seiiticfemia,  and  gonorrhoea  may  be  mentioned 
as  the  chief  predisposing  conditions,  while  excessive  use,  a  blow  or  a 
sprain,  or  exposure  to  cold,  are  common  exciting  causes  of  synovitis. 

The  chief  symptoms  are  pain  and  swelling.  Under  direct  pressure  or 
motion  the  former  is  increased.  Both  are  due  to  hyperfemia  and  the 
distention  of  the  capsule  from  the  effusion.  Local  elevation  of  tempera- 
ture is  present. 

The  treatment  is  local  and  constitutional.  Eest,  in  the  position  of 
greatest  comfort,  is  essential.  Mild  extension,  to  a  degree  to  insure  fixa- 
tion, affords  marked  relief  in  most  cases.  Cold,  applied  by  means  of  the 
ice-bag,  is  invaluable.  Heat  may  be  used,  as  hot  cloths,  the  hot-Mater 
bag,  or  immersion  in  hot  water,  if  cold  is  distasteful  to  the  j^atient.  Ex- 
treme pain,  with  marked  distention,  should  be  immediately  relieved  by 
aspiration.  Among  the  many  tiseful  local  medical  remedies  are  lead- 
and-opium  wash,  vinegar,  soluti(m  of  the  snbacetate  of  lead,  and  various 
liniments.  Compression  by  means  of  absorbent  cotton  and  a  flannel 
bandage  is  useful  after  the  acute  symptoms  have  subsided. 

The  constitutional  treatment  looks  to  the  coiTection  of  any  existing 
disease,  the  administration  of  well-selected  articles  of  food,  and  tonics. 

When  synovitis  becomes  a  chronic  affection,  aspii-ation  and  irriga- 
tion of  the  capsule  and  joint  are  the  most  effectual  methods  of  treatment. 
The  manner  of  operating  is  as  follows :  Shave  the  joint  to  be  operated 
upon  thoroughly,  and  wash  it  with  ether  and  with  l-to-3n00  sublimate 
solution,  and  apply  a  disinfected  rubber  or  flannel  bandage  around  the 


344  A  TEXT-BOOK  OX  SURGERY. 

part,  leaving  a  small  space  exposed  at  the  i)oint  where  the  needle  is  to  be 
inserted.  Wash  out  the  instrument  and  needle  with  5-per-cent  carbolic- 
acid  solution.  Exhaust  the  aspirator,  push  the  needle  into  the  joint 
without  wounding  the  cartilage,  and  turn  on  the  .stop-cock  which  leads 
into  the  vacuum.  "When  the  iiow  ceases,  close  the  cock,  empty  the  cylin- 
dt-r  and  till  it  with  1-to-lOOOO  corrosive-sublimate  soluti(m,  and  force  this 
into  the  capsule,  to  its  full  distention  ;  then  exhaust  it,  place  (m  an  anti- 
septic dressing,  and  compress  and  lock  the  joint  with  plaster  of  Paris, 
liquid-glass,  or  some  fixed  apparatus  or  splint.  This  o])eration  maybe 
repeated  as  often  as  needed,  always  guarding  against  the  admission  of 
air  to  the  capsule,  which  may  usually  be  prevented  by  keejDing  the  cylin- 
der of  the  aspirator  higher  than  the  needle.  The  air  will  rise  and  remain 
in  the  upper  chamber  of  the  instrument.  The  joint  should  be  kejit  quiet 
for  about  six  weeks,  and  the  dressing  then  removed  to  allow  cai'eful 
passive  motion.     If  the  tluid  has  re-accumulated,  repeat  the  operation. 

Not  infrequently  a  synovitis  j^asses  uninterruptedly  on  into  an  orth- 
ritiSy  in  the  manner  already  described.  In  the  majority  of  instances, 
however,  the  destructive  lesions  of  the  joints,  which  obstinately  resist  all 
ordinary  methods  of  treatment,  commence  in  the  cancellous  tis.sue  of  the 
bone  in  the  immediate  vicinity  of  the  epiphyses ;  in  other  words,  destruc- 
tive arthritis  is  secondary  to  ostitis,  and  this  inflammation  of  bone  is 
almost  always  the  result  of  a  dyscrasia  and  an  accident  of  nutrition. 

The  opinion  which  has  prevailed — namely,  that  almost  all  lesions  of 
the  joints  were  caused  by  a  traumatism — has  been  proved  by  the  accumu- 
lated experience  of  many  accurate  and  conscientious  surgeons  to  be  un- 
scientiflc  and  without  foundation  in  fact. 

The  pathology  of  ostitis  has  been  dwelt  upon  on  a  previous  page. 
That  form  of  inflammation  of  bone  which  leads  into  arthritis  begins  in 
an  interference  with  the  normal  nutrition  of  the  growing  bones.  As 
stated,  the  primary  lesion  is  capillary  rupture  in  the  cancellous  expan- 
sions, near  the  articular  surfaces.  It  is  known  that  in  growing  bones 
rupture  of  a  vessel,  with  extravasation  of  blood,  is  very  common,  even 
in  healthy  children.  It  must  be  still  more  frequent  in  those  children 
suffering  from  any  dyscrasia  which  not  only  renders  the  capillary  waUs 
less  strong,  but  les.sens  the  reparative  power  of  the  tissues  involved  in 
the  area  of  extravasation.  I  am  not  inclined  to  accept  the  opinion  which 
prevails  to  a  considei'able  extent,  especially  with  German  surgeons,  that 
tuberculosis  is  so  frequently  the  caixse  of  ostitis  as  is  asserted.  Tubercu- 
lar ostitis  is  not  rare,  but  non-tubercular  ostitis  is  believed  to  be  more 
frequent. 

Diseases  of  Special  Joints. 

Of  tJie  Hip. — Arthritis  of  the  hip,  hip-joint  disease  (morhvs  00x0;  or 
morbus  coxariits),  is  a  frequent  and  formidable  affection,  and  one  which, 
in  many  instances,  will  baffle  the  best  medical  and  surgical  care  through 
months  and  years  of  suffering,  ending  in  destruction  of  the  joint,  and 
fiequently  in  death. 


DISEASES   OF  SPECIAL  JOINTS. 


345 


It  is  a  disease  of  cliildliood,  occumng  chiefly  in  the  period  of  rapid 
growth.  It  rarely  occurs  after  the  twelfth  year.  It  may  occur  at  any 
time  prior  to  this  age,  the  majority  of  cases  being  between  the  ages  of 
three  and  six  years. 

The  pathology  of  morbus  coxce  wiU  vary  with  the  peculiar  character 
of  the  lesion.  The  morbid  changes  which  occur  in  that  variety  which  is 
most  frequently  met  with  are  those  of  ostitis,  primarily,  followed  by 
destructive  arthritis.  The  initial  lesion  occurs  as  an  interference  with, 
or  aiTest  of,  nutrition,  near  the 
diaphyso  -  epijihyseal  cartilage 
(Fig.  380,  a).  It  may  begin  on 
the  diaphyseal  or  epiphyseal 
side.  According  to  Prof.  Gib- 
ney,*  the  initial  lesion  appears 
in  several  centers  of  ossification 
about  the  same  time.  It  is  an 
ostitis  rarefaciens.  The  can- 
cellous cavities  become  filled 
T\-ith  eml)ryonic  cells,  absoi-p- 
tion  of  the  lamellse  occurs,  the 
inflammatory  new  products  may 
undergo  a  slow  process  of  fat- 
ty metamorphosis,  may  become 
caseous,  or  the  process  may  ter- 
minate in  pus -formation.  The  development  of  the  bone  is  arrested,  the 
ostitis,  commencing  in  the  deeper  portions,  travels  in  aU  directions,  de- 
struction of  the  diaphyso-epiphyseal  cartilage  occurs,  with  separation 
of  the  epiphyses  {diastasis).  While  these  changes  are  going  on,  the 
lining  membrane  of  the  capsule  becomes  involved,  the  process  being  one 
of  chronic  synovitis,  which,  as  has  been  stated,  tei-minates  inevitably 
in  inflammatory  changes  in  the  tissue  proper  of  the  cajisule.  The  joint 
becomes  filled  with  the  products  of  inflammation,  the  ca^DSule,  over-dis- 
tended and  weakened,  ruptures  either  spontaneously  or  as  a  result  of 
motion,  and  dislocation  may  occur.  "With  separation  of  the  epiphysis 
and  destruction  of  the  neck  of  the  femur  shortening  ensues. 

While  those  just  desciibed  are  the  usnal  morbid  changes  in  hip- 
disease,  in  other  cases  the  pathology  is  different. 

Ilorhus  coxcB  may  begin  as  a  simjile  idiopathic  or  traumatic  synovitis, 
the  destruction  of  the  bone  being  secondary  and  commencing  from  the 
articular  surface,  progressing  inward.  It  may  commence  as  a  result  of 
injury  to,  or  an-est  of  nutrition  in,  the  digital  fossa  of  the  acetabulum, 
and  the  destruction  of  the  ligamentum  teres.  Again,  the  initial  ostitis 
may  be  situated  in  the  bones  which  form  the  cotyloid  cavity.  Lastly, 
hip-joint  disease  may,  in  rarer  instances,  result  from  a  peri-articular 
inflammation,  first  a  syndesmitis,  secondly  a  synovitis,  lastly  arthritis. 

Causes. — The  causes  of  hip-disease  are  chiefly  predisposing.     Any 


Fi(i.  380. — Section  of  normal  femur  of  a  boy  eight  years 
old.     (After  Gibney.) 


*  "  The  Hip  and  its  Diseases,"  Berminghani  &  Co.,  New  York,  1884. 


346 


A  T?:XT-BOOK   ON  SURGERY. 


dyscrasia  which  impairs  nutrition  in  general,  tends  to  destructive  ostitis 
in  children,  and  consequently  to  the  resulting  arthritis.  Traumatism 
may,  and  undoubtedly  does,  precipitate  the  inflammatory  jjrocess  in 
many  cases,  yet  the  ordinary  violence  to  which  this  joint  is  subjected 
will  rarely  induce  coxitis,  except  in  children  aflfected  with  some  constitu- 
tional disease.  Excessive  use  or  a  blow  may  i)roduce  synovitis,  but,  in 
a  hcaltliy  patient,  rapid  recovery  is  almost  certain.  If  diastasis  occurs 
as  a  result  of  accident,  ostitis  ensues,  and  destruction  of  the  joint  is  apt 
to  follow  ;  yet  this  is  an  exceedingly  rare  injury.  Rupture  of  the  liga- 
mentum  teres,  which  must  occur  in  a  traumatic  luxation,  rarely  leads  to 
destructive  arthritis  in  an  otherwise  healtln'  individual. 

The  si/mptoms  of  hip-disease  are  divisible  into  two  stages.  The  first 
stage  embraces  all  the  phenomena  of  intianimation,  up  to  a  positive  and 
appreciable  destruction  of  the  structures  which  enter  into  the  formation 
of  this  joint.  The  second  stage  embraces  the  phenomena  of  destruction, 
namely,  shortening  of  the  neck,  diastasis,  rupture  of  the  ligamentum  teres 
and  capsular  ligament,  and  luxation. 

Among  the  earlier  signs  of  this  disease  is  pain,  referred  directly  to  the 
hip,  or  it  may  be  to  the  hip-  and  knee-joint,  of  the  affected  side,  and  in 
some  instances  the  pain  is  felt  wholly  in  the  knee  of  the  same  side.  This 
symptom  is  most  exaggerated  at  night  and  in  the  early  morning  hours, 
and  after  the  child  begins  to  move  about  may  disappear.  The  distribu- 
tion of  the  obturator  nerve  to  both  articulations  will  account  for  the  reflex 
sensibility  in  the  knee.  In  a  certain  number  of  cases  the  patients  will 
deny  all  sense  of  pain,  and  even  under  pressure  may  not  exhibit  signs  of 
suffering.  In  children  this  effort  at  concealment  (not 
uncommon)  is  incited  by  the  fear  of  being  subjected 
to  surgical  treatment.  If,  however,  a  careful  exami- 
nation is  made,  rigidity  of  the  muscles  about  the  hip 
will  be  evident.  In  standing  erect,  the  weight  of  the 
body  will  be  brought  upon  the  sound  extremity,  the 
gluteal  fold  on  the  affected  side  is  partially  obliter- 
ated (Fig.  381),  and  in  walking  there  is  almost  always 


Fio.  382.— (After  Sayre.) 

a  perceptible  limp.  The  iliacus,  jisoas,  and  adductor 
muscles  are  usually  in  an  abnomial  state  of  tension  ; 
-hence  the  initial  flexion  of  the  thigh,  and  outward 
rotation  or  eversion  of  the  foot. 
Rigidity  of  the  psoas  and  iliacus  muscles — one  of  the  more  positive 
early  sym^jtoms  of  hiiJ-disease— may  be  demonstrated  in  the  following 


Fio.  381.— (After  Sayre.) 


DISEASES   OF  SPECIAL  JOINTS. 


347 


Fig.  SS3.—(  Aft  Li- 


re.) 


Fig.  384.— (After  Sayre.) 


manner :  If  the  patient  be  stripped  and  laid  flat  on  the  back,  on  a  hard, 
level  .surface,  and  both  leffs  drawn  up  (Fig.  382),  it  will  be  seen  that  the 
sacrum,  spines  of  the  vertebra?,  the  scapuke,  and  occiput  rest  in  contact 
with  the  table.  If  the 
sound  leg  be  now  ex- 
tended and  the  pop- 
liteal space  brought 
well  down  against  the 
surface  of  the  table, 
the  lumbar  spine  is 
only  very  slightly,  if 

at  all,  lifted  from  the  table  (Fig.  383).  If  there  be  rigidity  of  the  mus- 
cles named,  as  a  result  of  hip-di.sease,  on  the  suspected  side,  when  the 
effort  is  made  to  bring  this  leg  into  a  position  parallel  with  the  sound 

one,  it  will  be  seen 
that  extension  of  the 
thigh  is  limited,  and 
that  the  motion  of  the 
hip-joint  is  transfeiTed 
to  the  lumbar  verte- 
brse,  so  that  when  the 
popliteal  space  touch- 
es the  table  the  lumbar  spines  are  lifted  from  one  to  three  inches  from  its 
surface  (Fig.  384). 

The  duration  of  the  first  stage  varies  from  two  or  three  months  to  as 
much  as  one  year,  and  in  exceptional  cases  longer. 

In  the  second  stage  the  thigh  is  further  flexed  on  the  abdomen,  adduc- 
tion is  more  pronounced,  and  shortening  is  present  in  a  degiee  varying 
with  the  extent  of  destructive  ostitis  in  the  acetabulum,  or  head  and  neck 
of  the  femur,  and  to  the  character  of  the  luxation.  In  the  usual  position 
of  the  foot  of  the  affected  side,  in  this  stage,  the  great  toe  or  inner  surface 
of  the  tarsus  rests  upon  the  dorsum  of  the  well  foot,  or  on  the  spine  of 
the  tibia.  The  shortening — which  may  be  determined  by  measuring  from 
the  anterior-superior  spine  of  the  ilium  to  the  inner  malleolus— will  vary 
from  half  an  inch  to  several  inches.  Nelaton's  or  Callaway's  test — 
already  given  in  the  article  on  fractures  of  the  femur — wiU  demonstrate 
that  the  shortening  has  occurred  above  the  trochanter. 

Suppuration  occurs,  the  capsule  gives  way,  and  sooner  or  later,  if 
surgical  interference  is  delayed,  sinuses  open  through  the  skin,  about  the 
trochanter,  or  in  the  groin.  Perforation  of  the  acetabulum  takes  place  in 
a  certain  proportion  of  cases. 

Diagnosis. — Disease  of  the  hip-joint  may  be  differentiated  from  bur- 
sitis, peri  articular  inflammation,  rheumatism,  neuralgia,  sacro-iliac  dis- 
ease, or  ostitis  of  the  troclianter  or  ilium.  It  is  also  important  to  deter- 
mine whether  the  initial  lesion  is  a  synovitis  or  an  ostitis. 

Synovitis  may  be  caused  by  excessive  iise  of  the  joint,  by  strain  or 
concussion,  by  sudden  exposure  to  cold,  or  it  may  result  as  a  symptom 
of  gout  or  rheumatism.     It  is  a  i)ainful  affection  from  its  incix^iency,  and 


348  A  TEXT-BOOK  ON  SURGERY. 

the  pain  increases  with  the  march  of  the  effusion  into  the  joint  and  the 
distenticjn  of  tlie  capsule.  Mt)tion  increases  the  pain,  which  is  usually 
so  severe  that  all  movement  of  the  joint  is  firmly  resisted.  The  cause 
may  usually  be  traced  to  an  injury.  Synovitis  due  to  gout  or  rheuma- 
tism occurs  usually  in  adults ;  coxitis  is  practically  a  disease  of  child- 
hood. 

When  ostitis  is  the  initial  lesion,  the  approach  of  the  disease  is  insidi- 
ous and  much  less  painful.  When  present,  the  pain  in  ostitis  of  the  head 
and  neck  of  the  femur  is  deep-seated  and  dull,  and  motion  is  comiiara- 
tively  free.  Rotation  and  pressure  of  the  head  upon  the  capsule  and  in 
the  acetabulum  do  not  produce  the  sharp  sense  of  pain  felt  in  synovitis. 
Ostitis  is  the  nile  in  children,  synovitis  in  adults. 

Bursitis  about  the  hip  is  rare.  The  sac  between  the  caj^sule  and  the 
conjoined  tendon  of  the  psoas  and  iliacus  muscles,  and  those  situated 
between  the  tendons  of  the  gluteus  maximus,  medius  and  minimus  and 
the  great  trochanter,  and  that  between  the  quadratus  femoris  and  the 
lesser  trochanter,  may  one  or  all  be  involved.  Inflammation  in  one  or 
more  of  these  bursae  may  be  recognized  by  the  limited  extent,  as  well  as 
the  acuteness  of  the  pain  elicited  by  direct  digital  pressure  immediately 
over  the  known  position  of  the  sac.  Pain  in  the  knee  is  not  i)resent  in 
bursitis  at  the  hip.  Kigidity  is  not  general  in  the  muscles  about  the 
joint. 

Peri-articular  ivflammation  is  a  painful  affection,  causing  marked 
lameness  from  the  start ;  it  is  accompanied  by  local  swelling  and  tender- 
ness if  superficial,  and  by  exacerbations  of  temperature,  all  of  which 
will  render  it  easy  of  recognition. 

Muscular  rheumatism  is  rarely  confined  to  the  muscles  of  the  hip. 
It  is  an  expression  of  a  c(mstitutional  condition  which  can  not  but  be 
elicited  by  a  careful  history  and  study  of  the  case.  The  pain  is  more 
severe  and  more  early  recognized  than  in  coxitis.  The  j.ainful  territory 
may  be  outlined  by  fixation  of  the  joint  and  digital  pressure  upon  the 
muscles  involved. 

Neuralgia  occurs  very  rarely  in  children,  in  the  period  when  hip- 
disease  is  most  likely  to  appear.  The  exacerbations  of  pain  are  more 
sudden  in  development  and  acute  in  character,  and  occur  with  greater 
frequency  and  regularity  than  in  hip-disease.  Motion  is  tolerated  better 
in  neuralgia  than  in  coxitis.  The  symptoms  of  ostitis  which  lead  to 
arthritis,  if  carefuUy  studied,  wiU  show  a  wide  difference  from  neuralgia 
about  the  hip. 

In  arthritis  or  ostitis  at  the  sacro-iliac  junction  pain  is  caused  by 
forcibly  pressing  the  ilium  against  the  sacrum.  The  same  symptoms 
may  be  elicited  by  direct  pressure  jiosteriorly  over  the  sacro-iliac  articu- 
lathm.     Motion  at  the  hip  is  only  slightly  if  at  all  emban-assed. 

Prognosis. — In  hip-joint  disease  commencing — as  is  the  rule — in 
ostitis  or  epijihysitis,  the  prognosis  is  bad  as  regards  restoration  of 
function.  Partial  or  complete  anchylosis,  with  a  variable  degree  of 
shortening,  will  result,  in  the  vast  majority  of  cases,  no  matter  how 
skillfully  treated.     The  proportion  of  fatal  cases  can  scarcely  be  de- 


DISEASES  OF  SPECIAL   JOINTS.  349 

termined.  It  is  safe  to  say  that  at  least  twelve  per  cent  of  all  cases 
in  which  the  lesion  begins  as  an  ostitis  end  in  death  in  from  one  to  six 
years. 

In  traumatic  synovitis  of  the  hip  the  prognosis  is  favorable.  A  resto- 
ration of  function  is  the  rule. 

Treatment. — The  treatment  of  hip-disease  may  be  divided  into  me- 
chanical, operative,  and  constitutional. 

In  the  early  stage  of  coxitis  rest  to  the  inflamed  articulation,  in  the 
position  of  least  discomfort,  is  essential.  Fixation  of  the  muscles  which 
act  upon  and  about  this  joint  can  be  best  secured  by  extension  from  the 
lower  part  of  the  thigh  and  the  leg  or  foot,  and  counter-extension  fi-om 
the  perinfeum.  To  accomplish  extension  satisfactoilly  the  limb  should 
be  brought  into  the  straight  position — that  is,  about  parallel  with  the  axis 
of  the  body. 

If  a  child  with  hip-disease  be  seen  very  early  in  the  history  of  this 
affection,  flexion  of  the  thigh  upon  the  abdomen  will  not  have  occurred 
to  any  extent,  but,  in  cases  where  the  inflammatory  process  has  gone  on 
for  some  time,  the  iliacus  and  psoas  and  adductor  muscles  will  have  be- 
come rigid  and  shortened  to  such  an  extent  that  the  thigh  can  not  be 
immediately  brought  out  straight. 

In  the  former  class  of  cases  the  apparatus  about  to  be  described 
can  be  at  once  adjusted  ;  in  the  latter,  extension  in  the  recumbent 
posture  is  necessary  untU  the  shortening  in  the  ilio-psoas  muscles  is 
overcome. 

In  fact,  since  in  all  cases  some  time  must  elapse  between  the  discovery 
of  the  lesion  and  the  preparation  of  the  mechanical  apparatus,  it  is  a  wise 
practice  to  put  the  patient  to  bed  at  once,  and  apply  the  extension  as 
follows  :  Cut  two  strips  of  mole-skin  plaster,  from  one  inch  and  a  half  to 
two  inches  wide,  and  long  enough  to  extend  from  six  inches  above  the 
trochanter  to  below  the  sole  of  the  foot.  Adjust  one  to  the  outer  and 
one  to  the  inner  aspect  of  the  thigh,  allowing  the  upper  end,  which  is  to 
be  doubled  back  upon  itself  and  woven  in  with  the  roller,  to  extend  four 
or  five  inches  above  the  level  of  the  trochanters.  Mold  them  carefully  to 
the  contour  of  the  limb,  bringing  the  strips  exactly  over  the  inner  and 
outer  condyles  of  the  femur,  and  hold  them  by  a  well-adjusted  bandage, 
beginning  from  above.  In  order  to  prevent  the  plaster  from  wrinkling,  it 
is  necessary  to  clip  it,  at  intervals  of  an  inch  or  two,  with  the  scissors, 
obliquely  upward  from  each  edge.  The  strips  should  be  made  to  adhere 
to  the  skin  to  within  six  inches  of  the  malleoli,  not  so  much  that  traction 
below  the  knee  is  necessary,  but  because  the  complete  extension  of  the 
leg  on  the  thigh  enforces  more  perfect  quiet.  The  bandage  is  commenced 
just  at  the  level  of  the  great  trochanter,  and  that  portion  of  the  strips 
which  extends  above  this  is  to  be  turned  down  and  worked  in  with  the 
roller. 

That  part  of  the  plaster  which  is  exposed  near  the  foot  should  be 
doubled  h\  laying  a  second  strip  of  equal  width  on  this,  the  adhesive 
surfaces  coming  together.  In  this  way  it  is  not  only  strengthened,  but  is 
prevented  from  sticking  to  the  di-essing. 


350 


A  TEXT-BOOK  ON  SURGERY. 


The  extension-weight — varying  from  two  to  seven  or  eight  pounds — is 

applied  as  in  Buck's  apparatus  (page  304).     The  dorsal  decubitus  should 

be  maintained,  for,  if  the  sitting  posture  is  assumed,  the  iliaciis  and 

psoas  muscles  are  not  materially  affected  l)y 
the  extension.  To  secure  this  result  the 
long  splint  of  Hamilton  should  be  applied 
from  the  axilla  along  the  thigh  and  leg,  and 
firmly  secured  by  a  bandage  carried  around 
the  chest,  pelvis,  and  thigh. 

As  soon  as  the  thigh  is  fully  extended  the 
following  mechanism  should  be  adjusted. 
It  consists  of  a  long  Sayre  splint  (Fig.  385) 
and  the  high  shoe  and  crutches  of  Hutchi- 
son. The  splint  is  composed  of  a  long,  hol- 
low steel  shaft,  attached  above  to  a  pelvic 
belt  by  a  joint  capable  of  motion  in  every 
direction.  To  the  belt  two  perineal  bands 
are  attached.  Opposite  the  knee  a  strap 
and  pad  are  fixed,  which  serve  to  steady  the 
leg  at  this  joint.  Fitting  snugly  within  this 
hollow  shaft  is  a  bar  of  steel  which  may  be 
slid  up  or  down  by  a  ratchet  and  key,  and 
locked  in  any  position.  The  lower  end  of 
this  rod  is  turned  at  an  angle  of  90°  to  the 
shaft,  and  fitted  with  a  spring-catch  into  a 
socket  on  the  sole  of  the  shoe.     In  apphang 

the  instrument  shorten  the  shaft  as  much  as  possible,  fasten  the  belt 

around  the  pelvis  just  above  the  trochanters, 

and  then  the  perineal  bands,  one  on  either  side. 

The  shoe  is  put  on,  the  spring-catch  fixed  in  the 

socket  at  the  sole,  and  the  knee-pad  buckled. 

The  shaft  of  the  instrument  is  now  lengthened 

by  the  key  until  a  fair  and  comfortable  degree 

of  extension  is  secured.    The  shoe  iipon  the  foot 

of  the  sound  side  should  be  raised  from  one 

inch  to  one  inch  and  a  half,  and  the  patient 

made  to  move  about  on  crutches.    Upon  retiring 

for  the  night  the  extension  employed  at  first 

should  be  resumed.    This,  the  combination  meth- 
od, is  shown  in  Fig.  386.     The  effectiveness  of 

this  plan  of  treatment  has  been  satisfactorily 

demonstrated  in  a  number  of  instances.     The 

advantages  are :   1.  The  patient  is  able  to  move 

about  and  obtain  the  benefit  of  out-of-door  life, 

while  the  hip  is  held  in  extension  and  practical- 
ly immovable.     2.  The  high  shoe  and  crutches 

hold  the  lame  foot  and  leg  suspended.     3.  In     ^^^  sse.-j^e  author',  comm. 

case  of  a  fall,  the  sjilint  prevents  concussion  in  uatiou  meUiod. 


Fig.  385. 


DISEASES   OF   SPECIAL  JOINTS.  351 

the  joint.  4.  Tlie  niglit-extension  prevents  spasmodic  contraction  of  the 
muscles  and  pain  from  unguarded  movements  during  sleep. 

The  length  of  time  for  which  this  treatment  should  be  continued 
will  be  determined  by  the  result  achieved.  It  is  often  a  necessity 
for  one,  two,  or  three  years,  and  sometimes  even  longer,  and  should 
be  worn  for  several  months  after  all  active  symptoms  of  coxitis  have  dis- 
ai^peai'ed. 

The  constitutional  treatment  of  this  disease  is  of  great  importance. 
Carefully  selected  diet,  out-of-door  life,  cod-liver  oil  and  the  hypophos- 
phites  of  lime  and  soda,  and  tonics,  are  indicated. 

If  the  long  splint  can  not  be  obtained,  the  high  shoe  and  crutches 
should  be  used  while  the  patient  is  out  of  bed,  and  the  extension  em- 
ployed while  lying  down. 

In  the  second  stage  of  hip-disease  operative  interference  may  be 
demanded:  (1)  To  relieve  pain  on  account  of  suppuration  and  the  re- 
tention of  pus,  or  to  prevent  sepsis  from  insufficient  drainage ;  (2) 
to  arrest  ostitis  in  the  head  and  neck  of  the  femur,  and  in  the  ace- 
tabulum. 

When  pain  is  so  severe  that  fixation  with  extension  wdll  not  afford 
relief,  it  is  safe  to  conclude  that  distention  of  the  capsule  exists,  or  that 
in  the  structures  which  fonn  the  joint,  or  are  immediately  around  it, 
suppuration;  has  occurred  to  such  a  degree  that  free  puncture  or  incision 
is  necessary.  For  this  jjurpose  the  aspirator  may  be  employed,  or  the 
bistoury. 

Although  the  propriety  of  opening  the  joint  freely  and  removing  aU 
diseased  bone — exsection  of  the  hip-joint — when  positive  symptoms  of 
destructive  ostitis  are  present,  is  questioned  by  some  surgeons,  the 
weight  of  oi^inion  is  on  the  side  of  operative  interference. 

Admitting  that  probably  a  majority  of  all  cases  in  which  destruc- 
tion of  bone  occurs  recover,  with  more  or  less  complete  anchylosis, 
without  exsection  and  without  oj^erative  interference  of  any  kind,  the 
drainage  through  the  sinuses  which  lead  out  through  the  skin  being 
sufficient ;  and  that  the  operation  is  not  without  danger  to  life  ;  and 
when  not  fatal  is  not  successful  in  all  cases,  the  ostitis  continuing  or 
recurring  after  exsection — the  argument  in  favor  of  operation  is  not 
answered. 

Exsection  of  the  hip-joint  is  not  a  dangerous  operation  when  done 
in  the  earlier  stages  of  destructive  osteo-arthritis,  before  the  patient's 
vitality  is  impaired  by  continued  suppuration,  septic  absorption,  and 
amyloid  changes  in  the  viscera.  Moreover,  in  the  cases  which  recover 
without  surgical  interference  the  dead  bone  and  products  of  inflammation 
must  be  carried  away  thi-ough  tortuous  channels,  in  which  absorption  is 
more  apt  to  occur  than  when  direct  drainage  is  established.  The  opera- 
tion removes  at  once  all  diseased  tissue  and  leaves  a  fi-ee  and  open  wound 
for  drainage. 

After  exsection  the  wound  should  be  packed  with  sublimate  gauze 
and  treated  by  the  open  method — not  even  partially  closed  by  sutures. 
The  gauze  may  be  changed  every  few  days,  the  wound  ii'rigated  with 


352 


A  TEXT-BOOK   ON  SURGERY. 


l-to-3000  sublimate  solution,  and  again  filled.  Extension  by  the  weight 
and  pulley,  in  the  dorsal  decubitus,  is  necessary  for  from  three  to  six 
weeks  after  the  ojieration,  unless  the  cliild  is  strapped 
in  the  wire  breeches  recommended  by  Prof.  Sayre 
(Fig.  387)  immediately  after  the  exsection.  The 
chief  recommendation  of  this  ajjparatus  is  that  it 
allows  the  jiatient  to  be  carried  out  of  doors,  or 
about  the  house,  with  perfect  freedom  from  motion 
or  pain.  The  chief  objection  is  its  costliness,  which 
puts  it  out  of  the  reach  of  many  patients.  The  ex- 
tension in  bed  is  very  satisfactory  in  its  results,  and, 
with  attenticm  to  ventilation  and  the  amusement  and 
entertainment  of  the  little  patient,  the  couhuement 
need  not  be  a  formidable  objection. 

AVhen  the  wire  apparatus  is  used  the  following 
directions  should  be  carried  out :  Pad  the  instru- 
ment well,  so  that  too  great  pressure  at  any  one 
point  may  not  occur.  Place  the  patient  in  it  so  that 
the  anus  will  project  well  over  the  crotch  of  the 
breeches.  It  is  well  to  insert  a  piece  of  protective 
under  the  sacrum  and  buttocks  to  prevent  soiling. 
Fasten  the  well  leg  and  the  body 
to  the  insti'ument  by  rollers. 
Lay  the  extremity  of  the  affect- 
ed side  in  its  splint,  and  screw 
the  foot-piece  up  until  it  touch- 
es the  sole.  Apply  two  strips 
of  adhesive  plaster  in  the  same 
manner  as  heretofore  given,  at- 
tach these  to  the  foot-piece,  and 
make  the  necessary  extension  by  turning  the  screw 
in  the  proper  dix-ection  {Fig.  388).  Passive  motion 
to  the  ankle  and  knee  should  be  made  at  the  end 
of  two  or  three  weeks,  and  repeated  weekly.  Af- 
ter from  four  to  six  weeks,  no  matter  whether  the 
wire  apparatus  is  used  or  extension  in  bed  employed, 
the  long  splint,  high  shoe  and  crutches  should  be 
adjusted,  and  the  case  treated  as  given  for  the  fii'st 
stage. 

Within  the  last  few  years  the  operation  of  drill- 
ing into  the  neck  and  head  of  the  femur,  in  cer-  fio.  sss.— (After  Sayre.) 
tain  cases  where  the  initial  lesion  is  an  ostitis,  has 
been  advocated  and  perfonned  in  a  number  of  instances  by  Mr.  Mac- 
namara.*  The  results  so  far  have  been  of  a  nature  to  encourage  a 
repetition  of  this  procedure.  The  object  of  the  operation  is  to  give  es- 
cape to,  and  secure  drainage  of,  the  products  of  the  inflammatory  pro- 


Fio.  387.— (After  Sayre.) 


"Gibney  on  the  Hip."     Bermingham  &  Co.,  Neiv  York,  1884. 


DISEASES  OF   SPECIAL  JOINTS.  353 

cess,  at  or  near  the  epiphysis,  and  thus  prevent  disintegration  of  the 
bone  and  invasion  of  the  joint.  To  be  beneficial  it  must  be  done  early 
in  the  process. 

The  operation  is  neither  dangerous  nor  difficult.  A  longitudinal  in- 
cision, from  two  to  three  inches  in  extent,  is  made  along  the  middle  of 
the  trochanter,  down  to  the  bone.  The  wound  should  be  deep  enough  to 
permit  the  fingers  to  locate  the  neck  of  the  femur,  on  its  upper  and  lat- 
eral surfaces,  so  that  the  drill  may  be  directed  along  its  center.  The 
chief  danger  to  be  avoided  is  entering  the  cavity  of  the  joint  by  caiTving 
the  drill  too  far.  In  the  single  case  in  which  I  performed  this  opera- 
tion, in  a  boy  about  eight  years  old,  a  button  of  bone  was  removed  by  the 
trephine  from  the  compact  substance  of  the  femur,  just  below  the  tro- 
chanter. A  drill,  about  three  sixteenths  of  an  inch  in  diameter,  was  then 
carried  up  through  the  neck,  a  distance  of  one  inch  and  a  quarter.  The 
direction  of  the  neck  was  readily  made  out  by  keeping  the  index -finger 
applied  to  the  upper  surface  of  the  neck  and  capsule.  After  the  opera- 
tion a  rubber  tube  was  inserted,  and  through  this  drainage  maintained 
until  all  discharge  ceased. 

Knee-joint. — Acute  synovitis  of  the  knee  is  frequently  of  traumatic 
origin,  resulting  from  the  excessive  strain  to  which  this  joint  is  subjected, 
and  also  on  account  of  its  exposed  position.  It  may  occur  in  the  history 
of  gout,  rheumatism,  gonorrhoea,  and  other  diseases. 

The  chief  symptoms  are  pain  and  swelling.  Pain  may  be  elicited  by 
motion,  or  by  direct  pressure  at  any  part  of  the  joint,  but  it  is,  as  a  rule, 
emphasized  over  the  coronoid  ligaments,  along  the  articular  margin  of 
the  tibia,  on  either  side  of  the  ligamentum  patelloe. 

The  treatment  consists  of  rest  and  fixation.  As  a  rule,  the  most 
agreeable  position  is  that  of  slight  flexion,  with  the  limb  elevated  and 
the  leg  resting  over  a  pillow.  Fixation  may  be  best  secured  by  exten- 
sion from  adhesive  strips,  reaching  from  just  below  the  knee  to  beyond 
the  sole.  The  strips  are  applied  in  the  same  manner  as  above  given.  The 
weight  will  vary  from  three  to  fifteen  pounds,  according  to  the  age  of  the 
patient.  Cold,  applied  by  means  of  the  ice  bag,  is  a  most  useful  remedy 
during  the  acute  stage  of  inflammation.  When  pain  is  very  severe,  and 
wlien  the  capsule  is  greatly  distended,  aspiration  is  indicated.  This 
should  be  done  with  all  antiseptic  precautions,  and  with  great  care  in 
preventing  the  entrance  of  air.  The  proper  instrument  is  shown  at  page 
63.  The  needle  may  be  introduced  on  either  side  of  the  patella,  at  the 
point  of  greatest  distention,  or  where  fluctuation  is  most  marked.  The 
diagnosis  may  be  made  positive  by  the  exploring  hypodermic  needle  and 
small  aspirator  (page  61).  Or,  when  the  tumefaction  is  evident  above  the 
patella,  the  needle  may  be  carried  from  above  downward,  behind  this 
bone.  After  the  excess  of  fluid  is  withdrawn  a  fair  degree  of  compres- 
sion should  be  exercised  by  enveloping  the  joint  with  borated  cotton, 
held  firmly  down  by  a  roller.  Passive  motion  of  the  joint  may  be  omitted 
for  as  long  as  four  weeks,  but  should  be  made  weekly  after  this. 

When  an  acute  synovitis  of  the  knee  becomes  rapidly  suppurative, 
with  the  symptoms  of  sepsis,  which  are  common  to  this  form  of  disease, 
23 


354  A  TEXT-BOOK   ON   SURGERY. 

evacuation  of  the  pus  and  irrigation  of  the  joint  are  indicated.  Tlie 
same  instrument  is  to  be  employed,  and,  after  the  fluid  is  withdrawn, 
the  capsule  is  distended  with  l-to-4()  carbolic-acid  or  l-to-l()()(X)  sublimate 
solution,  and  again  emptied.  This  ojjeration  sluudd  l)e  repeated  until 
the  liquid  comes  out  clear.  Compression  should  be  applied  in  the  same 
numner  as  before  given. 

If  the  joint  retills  with  pus,  and  the  symptoms  of  sepsis  are  not  re- 
lieved by  aspiration  and  irrigation,  it  should  be  opened  and  free  drain- 
age estal)lished.  It  is  usually  safer  to  make  one  incision  on  either  side 
of  the  patella,  directly  into  the  capsule,  introduce  the  closed  dressing- 
forceps  and  bore  thi'ough  the  ligament,  making  a  counter-opening  on 
the  lower  lateral  aspects  of  the  joint.  It  is  only  necessary  to  incise  the 
skin  where  it  is  pushed  out  and  made  tense  by  the  jioint  of  the  for- 
ce\)s.  The  hole  may  be  enlarged  by  separating  the  blades  of  the  instru- 
ment. A  drainage-tube  should  be  caught  in  the  grasp  of  the  forceps 
before  it  is  withdrawn,  and  puUed  through  the  joint  as  the  instrument 
is  removed.  The  irrigation  may  be  constant  or  interrupted,  according 
to  the  severity  of  the  symptoms.  A  method  of  continuous  iiTigation  is 
shown  on  page  115. 

The  danger  of  anchylosis  after  acute  synovitis  of  the  knee-joint,  last- 
ing not  longer  than  from  one  to  six  weeks,  is  slight.  It  is  always  great 
after  supjJiirative  synovitis  and  arthritis,  and  in  osteo-arthritis  is  almost 
inevitable. 

Destructive  osteo-arthritis  of  the  knee-joint  may  commence  as  a  syno- 
vitis, either  traumatic  or  idiopathic,  or  it  may  begin  as  an  ostitis,  in  or 
near  the  epiphysis  of  the  tibia  or  femur,  the  joint  being  secondarily  in- 
volved. The  latter  is  by  far  the  more  frequent  source  of  chronic  knee- 
joint  disease. 

Symptoms. — Pain  is  not,  as  a  rule,  a  prominent  symptom  of  ostitis 
near  the  knee,  and,  when  the  joint  has  become  involved  and  the  carti- 
lages eroded,  in  many  instances  the  degree  of  pain  felt  is  far  from  being 
proportionate  to  the  gravity  and  extent  of  the  destructive  process.  In 
exceptional  cases  pain  may  be  excessive,  and  may  be  felt  in  the  hip  as 
well  as  the  knee,  or  may  be  referred  entirelj^  to  the  acetabulum.  As  the 
disease  progresses  the  swelling  increa.ses,  and  Is  due  not  only  to  effusion 
Into  the  capsule,  but  also  to  thickening  of  the  ligaments,  and,  to  a  certain 
extent,  to  changes  in  the  ends  of  one  or  both  bones  which  enter  into  the 
formation  of  this  articulation.  Later  the  ligaments  give  way,  and  dislo- 
cation of  the  tibia  backward,  with  sliglit  outward  rotation,  occurs  (sub- 
luxation). In  the  earlier  stages  of  the  ostitis  certain  constitutional 
symptoms  appear,  and  remain  throughout  the  course  of  the  disease. 
Septic  fever  is  present  in  a  varying  degree,  and  with  it  impairment  of 
function  in  the  digestive  apparatus. 

Treatment. — Whenever  destructive  ostitis,  -with  arthritis,  at  the  knee 
exists,  the  loss  of  function  of  the  joint  is  almost  inevitable.  In  fact,  an 
effort  to  preserve  motion  in  such  a  joint  is  of  doiibtful  propriety,  since 
the  disease  is  apt  to  be  exaggerated  if  complete  fixation  is  not  secured 
and  maintained.    If  an  opening  is  not  made  into  the  capsule  it  ultimately 


DISEASES   OF   SPECIAL  JOINTS. 


355 


ruptures,  and  a  sinus  gives  exit  to  the  products  of  inflammation.  Opera- 
tive interference  is  usually  indicated  as  soon  as  erosion  of  the  articular 
surfaces  can  be  made  out,  or  as  soon  as  the  symptoms  point  to  the  com- 
munication of  a  focus  of  ostitis  with  the  cavity  of  the  joint.  The  recog- 
nized methods  of  procedure  may  be  given  as  follows :  (1)  Fixation  of 
the  joint  without  drainage  ;  (2)  fixation  with  drainage  ;  (3)  opening  into 
the  joint,  with  removal  of  the  diseased  tissues — exsection  or  gouging. 

The  first  method  is  of  the  most  conservative  character,  and  is  only 
justifiable  in  the  milder  class  of  cases,  where  pain  is  not  severe,  and 
where  sepsis  is  practically  absent.  If  the  leg  can  be  brought  into  the 
straight  position  it  should  be  enveloped  in  a  plaster-of-Paris  cast,  and 
allowed  to  remain  motionless  for  six  or  twelve  weeks,  if  no  urgent 
symptoms  appear.  The  dressing  should  then  be  removed  for  inspec- 
tion, and  reapplied.  This  may  be  continued  until  a  cure  results,  with 
anchylosis. 

If,  on  accoiant  of  subluxation,  the  straight  position  can  not  be  secured, 
extension  in  two  directions  (Fig.  389)  should  be  practiced  until  the  sub- 


Fio.  389.— (After  Savre.) 


luxation  is  reduced,  or  until  it  is  demonstrated  that  this  can  not  be  done 
without  operation. 

When  the  condition  of  the  joint  demands  drainage  the  same  method, 
of  fixation  may  be  practiced,  adding  only  one  or  more  windows  for  out- 
lets to  the  drainage-tubes. 

Operative  invasion  of  the  joint  may  consist  either  of  removal  of  the 
ends  of  the  bones  by  the  saw  or  gouge.  The  former  is  the  prefer- 
able operation,  and  is  now  no  longer  the  formidable  and  complicated 
method  of  a  few  years  back.  Carefully  and  properly  performed,  it  is, 
in  my  opinion,  to  be  ranked  with  the  conservative  operations  at  the 
knee,  and  is  entitled  to  a  consideration  in  the  earliest  stages  of  osteo- 
arthritis. 

Diseases  of  the  AnTcle-Joint. — The  pathology,  causes,  and  symptoms 
of  disease  at  the  ankle  do  not  differ  from  those  at  the  articulation  just 
considered. 

Synovitis  is  oftener  traumatic  than  idiopathic.  The  exposed  position 
of  this  articulation,  which  is  called  upon  not  only  to  sustain  the  entire 
body-weight,  but  is  also  frequently  subjected  to  great  lateral  strain,  ren- 
ders it  exceedingly  liable  to  injury. 


356  A  TEXT-BOOK  ON  SURGERY. 

The  symptoms  of  acute  tramnatic  synovitis  at  the  ankle  are  usually 
not  obscure.  Swelling,  pain,  and  heat,  following  prolonged  or  violent 
exertion,  a  twist,  sprain,  or  other  injury,  bear  strong  evidence  of  inflam- 
mation within  the  joint. 

The  injury  most  difficult  to  differentiate  from  intra-articular  synovitis, 
and  one  which  frequently  c()m]ilicates  synovitis  here,  is  inilaunuation  of 
the  sheaths  of  the  tendons  which  play  around  the  joint.  The  evidence 
of  tJiecitis  is  pain  in  the  track  of  the  tendon,  either  elicited  by  direct 
jiressure  or  by  placing  the  foot  slowly  in  a  position  which  will  cause  the 
greatest  tension  of  the  tendons,  and  then  requiring  the  patient  to  move 
the  foot  in  various  directions  which  are  resisted  by  the  operator.  To 
test  the  peronei  muscles,  carry  the  foot  well  inward,  hold  it  tirmly,  and 
ask  the  patient  to  turn  the  foot  out.  Thecitis  in  the  track  of  these 
tendons  will  arrest  the  effort  at  abduction  and  outward  rotation.  The 
reverse  of  this  manoeuvre  will  serve  to  demonstrate  a  similar  condition  in 
the  flexors  and  internal  rotators. 

Idiopathic  spnoc/tis  at  the  ankle-joint  is  less  painful  and  comes  on 
slowly.  Synovitis  from  exposure  to  cold,  gout,  or  rheumatism  is  fre- 
quently symmetrical,  attacking  either  both  ankles  at  the  same  time,  or 
first  one  and  then  the  other.  Traumatic  synovitis,  on  the  other  hand,  is 
almost  always  unilateral. 

The  prognosis  of  simple  synovitis  of  the  ankle,  when  proper,  vigor- 
ous, and  prompt  treatment  is  instituted,  is  in  general  favorable.  If  left 
alone  it  frequently  ends  in  anchylosis  or  destructive  osteo-arthritis. 

Treatment. — Acute  synovitis,  whether  of  traumatic  or  idiopathic  ori- 
gin, demands  rest,  with  an  elevated  position  of  the  foot.  Simple  cases 
will  require  no  more  than  this,  with  hot  or  cold  applications,  or  lead-and- 
opium  wash,  applied  by  soft  cloths  laid  loosely  around  the  ankle,  or 
blotting-paper  kept  wet  with  vinegar.  The  emi^loyment  of  compression 
will  depend  upon  the  sense  of  relief  it  may  give  the  patient.  Absorbent 
cotton  or  soft  sponges  may  be  used,  applied  carefully  with  a  flannel  or 
muslin  roller. 

Aspiration  of  the  joint  to  relieve  extreme  tension  from  effusion  ap- 
plies here  as  in  other  articulations.  The  needle  should  be  entered  in 
front,  between  the  anterior  margin  of  the  external  malleolus  and  the  con- 
tiguous surface  of  the  tibia,  away  from  the  vessels  and  nerves  which  are 
opposite  the  middle  of  the  joint. 

In  subacute  or  chronic  synovitis,  compression  is  always  indicated,  and 
will  often  cause  absorption  of  the  excessive  effusion  in  the  joint.  It  is 
especially  demanded  after  aspiration,  to  give  support  to  the  parts,  and 
to  prevent  a  further  effusion. 

Extension  is  indicated  when  its  employment  gives  relief  from  pain, 
which  rest  and  fixation  without  extension  do  not  afford.  Fixation  with 
liquid  glass  or  plaster  of  Paris  secures  rest  to  the  joint  in  most  cases,  and 
permits  of  locomotion  on  crutches. 

Arthiltis  of  the  ankle  is  often  due  to  ostitis  of  the  tibia  or  the 
astragalus. 

Tlie  symptoms  are  those  of  ostitis,  elsewhere  given,  and  the  diagnosis 


DISEASES   OF   SPECIAL  JOINTS.  357 

and  prognosis  do  not  differ  materially  from  similar  lesions  in  other 
articulations. 

When  osteo-arthritis  is  evident^operative  interference  is  indicated,  for 
the  reasons  that  (1)  early  incision,  by  giving  discharge  to  the  contents  of 
the  capsule,  retards  or  arrests  the  destructive  process  ;  (2)  the  common 
experience  of  surgeons  is  that  the  invasion  of  this  joint  is  practically 
w^ithout  danger  to  the  patient's  life. 

Complete  exsection  of  the  articular  ends  of  the  tibia  and  fibula,  and 
of  the  upper  half  of  tlie  astragalus,  is  rarely  called  for.  An  incision 
upon  the  side  which,  from  the  symptoms  present,  will  give  the  best 
access  to  the  diseased  bone,  and  the  free  use  of  Volkmann's  spoon  or  the 
scalloped  gouge  (page  37)  in  removing  the  dead  tissues,  will  usually 
suffice.  A  counter-opening  should  be  made,  so  that  thorough  drainage 
by  means  of  the  rubber  tube  may  be  maintained.  The  foot  should  be 
kept  at  rest,  and  the  patient  directed  to  go  on  crutches  until  several 
months  after  the  discharge  has  ceased,  and  the  sinus  closed.  The  oper- 
ation of  gouging  is  more  successful  in  osteo-arthritis  at  the  ankle  than 
in  any  other  articulation.  Complete  exsection  is  only  admissible  when 
the  destruction  is  very  extensive. 

Synovitis  and  osteo-arthritis  of  the  articulations  of  the  tarsus  and 
metatarsus  are  treated  upon  the  same  general  principles  as  just  given  for 
the  ankle. 

The  Shoulder -Joint. — Synovitis  of  the  shoulder  is  usually  general; 
in  rare  instances  it  may  be  local.  It  may  affect  the  general  synovial 
surface  of  the  capsule,  be  reflected  into  the  synovial  sheath  of  the  long 
head  of  the  biceps,  the  bursa  lander  the  tendon  of  the  subscapularis,  or 
that  beneath  the  infra-spinatus,  or  in  rare  instances,  especially  in  the 
earlier  stages,  one  or  more  of  these  bursse  may  be  inflamed,  while  the 
joint  is  not  invaded.  The  bursa  between  the  deltoid  and  tlie  cajjsule 
may  also  be  the  seat  of  bursitis,  although  this  sac  does  not  commimicate 
with  the  joint.  The  diagnosis  of  inflammation  in  one  or  more  of  the 
bursa;  about  the  shoulder  may  be  determined  as  follows  :  1.  Direct  digi- 
tal pressure  upon  any  single  bursa  will  indicate  the  sensibility  of  the 
part.  2.  Extend  the  forearm  fully,  grasp  the  hand  and  elbow  of  the 
l)atient,  and,  while  the  head  of  the  humerus  is  pulled  away  from  the 
glenoid  cavity,  direct  the  patient  to  make  strong  flexion,  which  the 
operator  firmly  resists.  If  inflammation  of  the  sheath  of  the  long  head 
of  the  biceps  exists,  pain  will  be  experienced  in  the  anterior  and  outer 
portion  of  the  joint  as  this  tendon  is  made  tense.  3.  When  the  bursa 
under  the  infra-spinatus  is  inflamed,  if  the  arm  is  rotated  inward,  and 
held  in  this  position,  pain  will  be  felt  when  the  tendon  of  this  muscle 
is  made  to  press  strongly  on  the  bursa,  in  any  effcu't  at  outward  rotation. 

An  opposite  manoeuvre  will  serve  as  a  test  for  the  bursa  beneath  the 
tendon  of  the  subscapularis.  In  general  synoriiiis  each  of  these  move- 
ments will  be  productive  of  pain,  and  the  differentiation  is  chiefly  between 
neuralgia  and  muscular  rheumatism.  In  neuralgia  the  pain  is  of  the 
]»eculiar  neuralgic  type.  It  is  rarely  constant,  the  exacerbation  appear- 
ing at  intervals  of  comparative  regularity,  and  extending  iu  the  recog- 


358  A  TEXT-BOOK  ON  SURGERY. 

nized  course  of  the  nerves.  Motion  is  not  painful  in  the  degree  which 
characterizes  either  synovitis  or  rheumatism,  and,  if  persisted  in,  the  sense 
of  pain  may  entirely  disappear.  Pressure  upon  the  nerves,  which  lead 
to  and  beyond  the  articulation,  will  at  times  cause  pain  similar  to  those 
felt  in  neuralgia  of  the  joint.  Swelling  is  not  a  feature  of  a  neurosis. 
In  rheumatism  of  the  muscles  about  the  joint  the  pain  is  snpei-ficial,  and 
may  be  elicited  by  digital  pressure  upon  the  substance  of  the  muscles. 
In  rheumatism  redness  is  more  apt  to  be  present,  and  the  area  of  swell- 
ing extends  farther  than  in  synovitis. 

The  treatment  of  synovitis  is  the  same  at  all  joints.  Artificial  exten- 
sion is  rarely  needed,  since  the  weight  of  the  extremity  is  sufficient. 

Aspiration  is  a  safe  and  efficient  means  of  relief  from  pain,  and  is 
indicated  when  there  is  marked  capsular  tension.  The  needle  should  be 
entered  through  the  center  of  the  joint  in  front.  Fixation  of  the  joint 
by  a  shoulder-caii  of  felt,  card-board,  or  leather,  should  be  .secured  im- 
mediately after  aspiration  (page  291).  When  ready  for  application,  lay 
upon  the  surface  of  the  board  which  is  to  be  nearest  the  skin  a  layer 
of  absorbent  cotton,  which  shall  be  wide  enough  to  extend  entirely 
around  the  arm  and  over  the  shoulder,  place  it  in  position,  and  se- 
cure snugly  by  a  tigure-of-8  bandage  around  the  arm  and  shoulder  (see 
Fig.  17).^ 

Acute  suppurative  synovitis  demands  an  immediate  evacuation  of  the 
purulent  contents  of  the  capsule  by  means  of  the  aspirator,  and,  if  the 
joint  refills  rapidly,  and  the  pain  and  temperature  continue  or  are  exag- 
gerated, it  .should  be  opened  and  thoroughly  cleansed  and  drained.  The 
incision  is  the  same  as  for  excision  of  the  head  of  the  humerus,  namely, 
from  the  anterior  internal  tip  of  the  acromion,  parallel  with  the  fibers  of 
the  deltoid  along  the  anterior  margin  of  the  great  external  tuberosity. 
The  capsule  is  opened  external  to  the  long  head  of  the  biceps,  and,  while 
traction  is  firmly  made  upon  the  edges,  the  cavity  may  be  thoroughly 
explored  and  cleansed.  It  is  of  vital  importance  that  in  this,  as  in  every 
cavity  which  is  the  seat  of  purulent  intiamniation,  drainage  should,  when 
possible,  be  established  from  that  portion  of  the  wound  which  is  most 
dependent.  As  the  patient  rests  in  bed  the  posterior  and  outer  part  of 
the  capsule  is  lowest.  A  dull-pointed  dressing-forceps  should  be  car- 
ried into  the  capsule  through  the  anterior  incision  and  bored  through 
the  inferior  posterior  wall  and  all  the  tissues  to  the  skin,  and  when  this 
is  pushed  ahead  of  the  instrument  an  incision  should  be  made  to  allow 
the  escape  of  the  instrument.  The  wound  is  stretched  by  opening  the 
jaws  of  the  instrument,  and  a  rubber  tube  pulled  into  place  as  the  in- 
strument is  withdrawn.  In  osteo-arthrifis  of  the  shoulder-joint  ex.section 
is  demanded. 

The  Elbow- Joint. —'Synovitis  of  this  articulation  need  not  be  sepa- 
rately considered.  The  same  general  principles  of  diagnosis  and  treat- 
ment apply  here  as  in  other  joints.  Destructive  osteo-arthritis  demands 
gouging  or  exsection.     The  operation  will  be  given  hereafter. 

The  Wrist- Joint. — Inflammation  of  the  synovial  membranes  of  the 
wrist  or  in  the  immediate  neighborhood  of  this  joint  is  of  frequent  occur- 


EXSECTIOXS   OF  THE   JOINTS. 


359 


rence.  It  is  usually  traumatic  in  orifrfn,  orcasionally  idiopathic.  It  may 
atfark  the  synovial  sac  between  the  ulna  and  radius  ;  that  between  the 
radius  and  the  fibro-cartilage  and  the  tirst  carpal  row  ;  the  general  syno- 
vial sac  between  the  first  and  second  rows  and  the  metacarpus  ;  or  that 
between  the  base  of  the  first  metacarpal  bone  and  the  trapezius  (Fig.  390). 
lufiammation  of  the  sheaths  of  the  tendons  on  the  dorsum  of  the  carpus 
or  on  the  palmar  surface  may  also  complicate  a  carpal  synovitis,  or  exist 
alone.  The  contiguity  of  these  various  structures  renders  a  positive  diag- 
nosis of  gi'eat  difficulty.  If,  when  the  bones  of  the  forearm  are  grasped 
near  theu-  center  and  pressed  together,  sharp  pain  is  elicited  at  the  wrist, 
synovitis  of  the  radio-carpal  sac  is 
indicated.  "When  the  swelling  is 
well  defined  at  the  edge  of  the  ar- 
ticular end  of  the  radius,  extends 
across  the  wrist,  and  is  limited  to 
the  situation  of  the  first  row  of  the 
carpus,  the  radio-carpal  sac  is  prob- 
ably alone  involved.  AA'hen  the 
several  ca^jsules  are  involved  the 
swelling  is  general.  In  thecitis 
the  pain  is  superficial,  and  usual- 
ly extends  for  some  distance  along 
the  tendons  above  and  below  the 
joint.  Contraction  of  the  mus- 
cles, the  tendons  of  which  are  in- 
volved, will  point  to  the  location  of 
the  inflammation.  Differentiation 
of  synovitis  from  CoUes's  fracture 
will  depend  upon  a  study  of  the  symptoms  of  this  lesion  already  given. 
Osteo-arthritis  in  its  earlier  stages  is  comparatively  a  painless  proce.ss, 
and  even  after  the  capsule  is  invaded  is  rarely  as  painful  as  an  acute 
synovitis. 

Treatment. — Synovitis  of  the  wrist  does  not  demand  separate  con- 
sideration. Destructive  osteo-arthritis  requires  gouging  or  exsection. 
Synovitis  of  the  metacarpal  or  interphalangeal  joints  should  be  treated 
on  general  principles  of  rest  and  fixation. 


Fio.  390.— (After  Gray.) 


EXSECTIOXS   OF  THE  JOUNTTS. 

The  Hip — Sayre^s  Operation. — Place  the  patient  on  the  sound  side  ; 
carry  the  point  of  a  strong  scalpel  perpendicularly  down  to  the  bone 
exactly  half-way  between  the  anterior-superior  spine  of  the  ilium  and. 
the  tij)  of  the  trochanter  major ;  *  cut  along  the  neck  of  the  femur, 
keeping   the   knife   firmly  in   contact  with  the  bone,   carrying  the  in- 


*  Tlie  extremity  should  be  held  parallel  with  the  axis  of  the  spine,  with  the  foot  normally 
rotated  outward. 


360 


A  TEXT-BOOK  ON   SURGERY. 


A 


)\ 


cision  midway  between  the  center  and  posterior  aspect  of  the  trochan- 
ter, and  then  curving  it  sliglitly  forward  as  it  passes  about  an  incli 
below  the  tuberosity  (Fig.  8t)l).  Through  this  incision,  which  divides 
the  capsule  and  thickened  periosteum,  insert  the  elevator  and  lift  the 
])eriosteal  investment  from  the  diseased  bone.  When  the  trochanters  are 
involved,  the  tendons,  inserted  into  these  eminences  and  into  the  digital 

fossa  just  above  the  great  tuberosity,  usu- 
ally require  to  be  detached  with  the  knife, 
the  point  of  which,  in  order  to  avoid  wound- 
ing any  vessels,  should  be  kept  in  close  con- 
tact with  the  bone.  As  soon  as  the  perios- 
teum is  freely  raised,  the  bone  should  be 
,  ,.  \   -      »      divided,  preferably  with  the  exsector  (Fig. 

ft/  \j     \     79),   and   the   upper   fragment   lifted   out 

with  the  elevator.  If  the  exsector  is  not 
used,  the  chain-  or  key-hole  saw  or  cuttiug- 
forceps  may  be  employed.  The  sawn  sur- 
face should  be  carefully  inspected  in  order 
to  see  if  the  disease  extends  farther  down 
the  bone,  necessitating  a  second  division. 
The  acetabulum  should  next  lie  exanuned, 
thoroughly  scraped  with  a  N'olkmaiin's 
spoon,  and  all  dead  tissue  removed.  Haem- 
orrhage is  usually  insignificant,  and,  if 
occurring,  should  be  arrested  as  the  oper- 
ation progresses.  The  wound  should  be 
thoroughly  irrigated  with  l-to-3()()()  subli- 
mate, all  shreds  of  tissue  and  particles  of 
bone  removed,  and  the  entire  cavity  tilled 
with  sul)limate  gauze,  well  packed  in,  and 
held  in  place  by  a  thigh  and  pelvic  spica. 
Fig.  .391.  Tlie  patient  should  now  be  put  to  bed  with 

an  extension  apparatus  applied  as  given 
for  the  early  treatment  of  hip-disease.  Sand-bags  may  ])e  laid  along 
the  leg  to  hold  the  foot  in  the  proper  degree  of  outward  rotation,  or  a 
splint  may  be  used.  The  long  splint  fi-om  the  axilla  to  the  heel  is  often 
required  to  prevent  a  child  from  sitting  upright  in  bed.  The  first  dress- 
ing is  changed  usually  about  one  week  after  the  operation,  and  once 
or  twice  a  week  thereafter.  After  four  or  five  weeks  the  combination 
method  should  be  employed,  and  the  case  treated  as  in  the  first  stage. 
Prof.  Sayre  prefers,  and  frequently  employs,  the  wire  breeches  for  the 
first  few  weeks  after  the  operation.  This  instrument  can  not  always 
be  obtained,  and  the  extension  in  bed  has  proved  perfectly  satisfac- 
tory. 

In  a  certain  proportion  of  cases  the  disease  is  not  arrested  by  the  first 
operation,  and  a  second  is  required. 

The  outline  of  the  parts  involved  in  this  operation  is  well  shown  in 
Fig.  392. 


EXSECTIOXS   OF  THE   JOINTS. 


361 


Fig.  .392. — 1,  Ligamentum  tere-s.  2,  E.xtemal 
obturator  muscle  aad  obturator  vessels.  .3, 
Circumflex  vessels.  4,  Conjoined  tendon  or 
psoas  and  iliacus.     (After  Braime.) 


The  Knee-joint. — Apply  Esmarch's 

bandage  as  higli  up  a.s  the  middle  of 

the  thigh.     Make  a  traa.sver.se  incis- 
ion from  the  level  of  the  posterior 

articular  surface  of  the  tibia  on  one 

side,  across  the  front  of  the  knee, 

over  the  middle  of  the  patella,  to  a 

corresponding  point  on  the  ojji^osite 

side  of  the  joint  (Fig.  393).     This  in- 
cision extends  fully  three  fourths  of 

the  circumference  of  the  extremity  at 

this  level,  and  should  divide  all  the 

tissues  down  to  the  ligaments,  and  the 

anterior  surface  of  the  patella.     The 

upper  flap  should  be   carefully  dis- 
sected and  drawn  upward  as  fast  as 

it  is  lifted  until  a  point  is  reached 

well  above  the  upper  margin  of  the 

patella.     In  like  manner  the  inferior 

Hap  is  turned  down  to  about  half  an 

inch  below  the  articular  plane  of  the 

tibia.    The  leg  should  now  be  strongly 

flexed  upon  the  thigh,  and  the  joint 

opened  by  dividing  the  ligament  it  m 

patella  and  capsular  ligament  just  even  with  the  interarticular  fibro-car- 

tUages.  The  lateral  ligaments  are  next 
severed,  when,  by  inserting  a  strong  hook 
into  the  piece  of  ligament  still  attached 
to  the  patella,  and  drawing  this  forci- 
bly upward,  the  crucial  ligaments  are  ex- 
posed. These  should  be  divided  by  care- 
ful touches  with  the  point  of  the  scalpel, 
the  proximity  of  the  popliteal  vessels 
being  borne  well  in  mind.  In  remov- 
ing the  patella  and  the  soft  tissues  con- 
nected with  it,  the  upper  flap  should  be 
rolled  up,  and  at  a  point  about  half  an 
inch  above  the  superior  margin  of  the 
patella  a  transverse  cut  made  to  divide 
everything  down  to  the  anterior  surface 
of  the  femur.  The  soft  parts  below  this 
line  should  now  be  dissected  off,  togeth- 
er with  the  patella,  and  any  portion  of 
the  synovial  sac  which  may  be  above 
this  line  should  be  carefully  removed 
with  the  curved  scissors. 

Careful  inspection  of    the   diseased 
surfaces  should  be  made,  in  order  to 


362  A  TEXT-BOOK  ON  SURGERY. 

determine  the  extent  of  bone  to  ])o  removed.     No  more  should  be  sac- 
rificed than  will  be  found  necessary  to  secure  the  removal  of  the  disease, 


Fig.  394. — Longitudinal  section  through  the  knee-joint.     1,  I'eroneal  nerve.    2,  Popliteal  vessels. 

(After  Braune.) 


EXSECTIONS   OF  THE   JOIXTS. 


363 


and,  at  the  same  time,  to  afford  a  sufficiently  broad  surface  for  the  appo- 
sition and  fixation  of  the  two  divided  bones.  The  ligament  of  Winslow 
should  now  be  divided  along  the  posterior  aspect  of  the  femur,  and  the 
soft  tissues  lifted— by  keeping  close  to  the  bone  with  a  dull  instrument 
(dry  dissector)— to  a  point  slightly  above  the  plane  of  section  of  the  bone. 
A  cloth  retractor  should  be  folded  so  as  to  protect  the  soft  jjarts,  and  the 
section  made  at  an  angle  of  90°  to  the  axis  of  the  shaft  of  the  femur. 
This  will  require  the  removal  of  from  one  fourth  to  one  half  inch  more  of 
the  inner  than  the  outer  condyle.  The  posterior  ligament  is  next  dis- 
sected from  the  upper  margin  of  the  tibia,  and  the 
soft  tissues  lifted,  down  to  the  line  of  section  in  this 
bone,  in  its  entire  circumference.  It  is  sawn  through 
also  at  an  angle  of  90°  to  the  shaft.  It  is  important, 
especially  in  operating  upon  children  and  young 
adults,  that  the  section  should  not  involve  or  too 
nearly  approach  the  epiphyseal  lines  of  these  bones, 
and  when  the  disease  runs,  in  one  or  more  limited 
spots,  deeply  into  the  cancellous  tissue,  it  is  prefer- 
able to  scrape  these  out  with  Yolkmann's  sjioon  rather 
than  make  a  second  section  through  the  entire  bone, 
at  a  level  that  would  sacrifice  the  epiphysis.  As  soon 
as  it  is  found  that  the  sawn  surfaces  fit  snugly,  in 
such  a  way  that  the  extremity  is  perfectly  straight, 
the  capsule  and  all  diseased  synovial  sacs  should  be 
dissected  out  with  the  forceps  and  curved  scissors. 
Great  care  must  be  taken  in  working  near  the  large 
vessels  at  the  posterior  j^ortion  of  the  joint. 

If  there  are  any  sinuses  communicating  with  the 
wound,  they  should  be  scraped  out  and  disinfected 
with  strong  sublimate  solution  (1-1000),  taking  care 
to  wash  out  the  excass  of  sublimate  by  irrigation  with 
a  weak  solution  (1-3000). 


Fig.  395. 


At  this  stage  of  the  operation  a  careful  search 
should  be  made  for  any  divided  vessels,  Avhich,  if 
found,  should  be  secured  at  once  with  juniperized 
catgut.  After  a  thorough  irrigation  with  1-3000  sub- 
limate, the  bones  are  brought  together  and  fastened 
by  transfixion  with  three  steel  drills  or  spikes.  The 
spike  is  shown  in  Fig.  395,  and  the  drills  in  Fig.  396. 
The  former  have  been  much  used  in  late  years  in  this 
operation,  and  are  highly  recommended.  I  prefer  the 
drills  on  account  of  their  easier  and  more  accurate  adjustment,  and  they 
have  given  perfect  satisfaction  in  my  service.     The  first  employed  were 


Fi 


306— Wyeth's  drills, 
with iKijustablc  h.inille, 
tor  fixation  of  ttio  bones 
in  Ivnee-joint  exscction. 


364 


A  TEXT-BOOK   ON  SURGERY. 


made  by  Mr.  Ford,  at  my  sngge.stion.  They  vary  in  lenirth  from  three 
to  live  and  six  inches,  are  between  (jne  sixteenth  and  one  t-iuhtli  of  an  inch 
in  diameter,  with  the  points  smaller  than  the  shaft,  so  tliat  as  they  are 
made  to  enter  and  transfix  the  bones  they  become  jammed,  and  are  held 
immovable  and  secnre.  Everything  being  in  readiness  for  the  drills,  a 
rubber  drainage-tube  is  carried  through  the  wound,  so  that  when  the 
bones  touch  each  otlier  the  tube  is  behind  these,  with  an  end  jirojecting 
on  each  side  of  the  knee,  or  two  short  pieces  may  be  inserted  from  either 
side.  The  sawn  surfaces  of  the  bones  are  now  brought  together,  and  iield 
perfectly  steady  by  a  skilled  assistant.  The  operator  approximates  the 
edges  of  the  wonnd  temporarily,  fixes  a  drill  into  the  handle  of  the  instru- 
ment, and,  at  a  point  about  one  inch,  or  one  inch  and  a  half,  below  the 
end  of  the  tibia,  and  upon  the  anterior  and  lateral  aspect  of  the  leg, 
makes  a  puncture  in  the  .skin.  In  this  puncture  the  point  of  the  drill  is 
carried,  passing  obliquely  down  to  and  into  the  bone,  in  such  a  way  that 
it  will  traverse  a  portion  of  the  tibia,  cross  the  line  of  approximation, 
enter  the  femur,  and  pass  into  this  bone  as  far  as  its  periosteum.  'I'he 
handle  is  now  removed  and  a  second  drill  introduced,  in  the  same  man- 
ner, from  the  opposite  side  of  the  tibia,  crossing  the  first  at  about  an 
angle  of  .90°.  A  thii-d  point  is  next  introduced,  on  the  anterior  surface 
of  the  femur,  and  is  made  to  travel  almost  directly  down  into  the  tibia. 
The  bones  are  now  firmly  fastened  together,  and  the  extremity  may  be 
lifted  from  the  foot  as  if  it  were  anchylosed  at  the  knee.  The  wound 
is  next  closed  with  catgut  sutures,  and  finally  irrigated,  dressed  with 
sublimate  gauze,  and,  outside  of  this,  a  thick  layer  of  borated  cotton, 
with  i)rotective  over  all.  In  order  to  steady  the  limb,  pieces  of  tin  or 
hoop-iron  (or  a  wooden  splint)  may  be  worked  in  as  the  bandage  is  being 
applied.  The  roller  should  be  firmly  drawn,  so  that  a  considerable  i)ress- 
ure  may  be  exercised  upon  the  j^art,  to  prevent  the  oozing  usually  so  pro- 
fuse after  Esmarch's  bandage  has  been  applied.  The  elasticity  of  the 
cotton  distributes  the  pressure  equally,  and  controls  haemorrhage  without 


Fig.  397. 


causing  discomfort.  It  is  the  practice  of  some  surgeons  not  to  apply  a 
single  ligature  in  this  operation,  but  to  rely  wholly  upon  compression  for 
the  control  of  bleeding.     It  is  better  to  search  for  and  tie  the  larger 


EXSECTIONS  OF  THE  JOINTS. 


365 


vessels  which  may  have  been  dividefl.  The  limb  is  allowed  to  remain 
undisturbed  for  from  ten  to  thirty  days.  The  drills  are  removed  at  about 
the  end  of  the  fourth  week.  As  in  all  the  antiseptic  operations,  the  indi- 
cations for  a  change  of  dressing  are  hjemorrhage,  high  temperatures,  and 
decomposition  of  the  discharge  beyond  the  zone  of  asepsis.  When  the 
wound  is  dressed,  careful  antisepsis  should  be  practiced.  Recovery,  with 
anchylosis  in  the  straight  position,  is  the  result.  No  effort  at  passive 
motion  should  be  entertained.  This  operation  has  met  with  remarkable 
success  within  late  years.  The  drills  or  nails  should  always  be  prefeiTed. 
When  they  can  not  be  obtained,  the  parts  may  be  held  in  apposition  by 
wiring  the  bones  together  and  applying  an  inteiTupted  plaster-of-Paris 
dressing,  as  shown  in  Fig.  397. 

The  Ankle-joint. — For  the  complete  exsection  of  the  articular  ends 
of  the  tibia  and  fibula  and  the  astragalus,  proceed  as  follows :  Commence 
an  incision  on  the  internal  surface  of  the  tibia,  about  two  inches  above 


Fig.  399. 


the  tip  of  the  inner  malleolus,  and  carry  it  directly  down  to  this  point, 
and  thence  directly  forward,  from  one  inch  to  one  inch  and  a  half  along 
the  tarsus,  in  the  direction  of  the  metatarsal  bone  of  the  great  toe  (Fig. 
398).  A  like  L-shaped  incision  is  made  upon  the  fibular  side  of  the  joint 
(Fig.  399).    These  incisions  divide  all  the  tissues  down  to  the  bone.    With 


Fio.  400. — Volkmann's  anterior  splint. 


the  Sayre  elevator  lift  the  periosteum,  with  its  attachments  to  the  super- 
jacent soft  tissues  undisturbed,  from  the  diseased  portions  of  bone.  Ex- 
pose the  outer  malleolus  and  fibula  as  high  as  it  is  deemed  necessary  to 
remove  this  bone,  and  divide  it  with  the  exsector  (or  chisel).  As  soon  as 
the  piece  is  removed  the  joint  is  thoroughly  exposed  to  view.     Now, 


366 


A  TEXT-BOOK  ON  SURGERY. 


further  lift  the  periosteum  of  the  tibia  and  tarsus,  and,  by  forcibly  bend- 
ing the  foot  inward,  dislocate  the  tibia  and  inner  malleolus  outward, 
through  the  wound  on  the  libular  side.  The  diseased  surface  may  he 
sawn  off  with  an  ordinary  saw.  or  witli  the  exsector.  The  section  through 
the  astragalus  may  be  made  with  a  gouge,  chisel,  or  a  key-hole  saw. 


O  « 

6S  a 


■Si 

61  S 


I 


Usually  no  vessels  of  importance  are  wounded  in  this  dissection,  since, 
by  keeping  beneath  the  periosteum,  they  are  lifted  with  the  tissues.  The 
periosteum  should  not  be  elevated  over  the  healthy  bone.  The  sawn 
surfaces  are  now  brought  in  apposition,  so  that  the  foot  will  be  at  an 
angle  of  90°  with  the  axis  of  the  leg.     Fixation  may  be  secured  by  trans- 


EXSECTIOXS  OF  THE   JOINTS. 


367 


Fio.  402.— The  foot  after  exseetiou  of  the  a^^tniyalus 
and  articular  encJs  of  tibia  and  fibula. 


fixion  with  small  steel  drills,  carrierl  obliquely  from  above  downward, 
entering  on  the  internal  aspect  of  the  tibia  and  the  external  sni-face  of 
the  fibula,  and  passing  into  the  astragalus  (in  the  same  manner  as  at  the 
knee).  The  wound  should  be  closed  with  catgut,  leaving  a  small  drainage- 
tube  to  pass  out  on  each  side.  The  rubber  should  not  be  pemiitted  to 
get  between  the  bones.  An  antiseiJtic  dressing  is  now  applied,  and  the 
foot  and  leg  placed  in  a  fracture-box  and  padded  to  hold  it  motion- 
less. If  the  drills  are  not  employed,  the  parts  should  be  held  in  ap- 
position while  a  plaster -of -Paris  dressing  is  applied,  which,  being 
"  set,"  is  fenestrated  on  both  sides  over  the  wounds,  in  the  same  man- 
ner as  shown  in  Fig.  350.  Or  a  Volkmann's  splint  (Fig.  400)  may  be 
applied  to  the  anterior  extremity 
of  the  foot  and  leg,  and  the  parts 
fixed  with  plaster  of  Paris,  or  sim- 
ple roller.  This  splint  may  be 
made  of  wood,  or  sheet-  or  hoop- 
ii'on,  properly  padded  with  anti- 
septic gauze.  A  useful  substitute 
may  be  made  from  several  pieces 
of  telegraph-wire. 

If  the  bones  are  not  extensively 
involved,  a  single  L-shaped  inci.sion 
will  suffice  to  expose  the  joint,  and 
the  dead  bone  can  be  removed  with  the  gouge  or  Yolkmann's  spoon,  and 
a  counter-Oldening  made  for  drainage.     This  operation  is  always  to  be 

prefeiTed  at  the  ankle. 
^^  When,  in  an  exsection  of  the  ankle,  the 

astragalus  is  so  much  involved  that  its  re- 

, ,,,  moval  is  necessary,  the  tipper  surface  of  the 

\.'>-/  X-'-''-  OS  calcis  should  be  smoothed  off  with  the 

.I'")'"!"  chisel  or  key-hole  saw,  and  brought  up  in 

|/V'\  apposition  with  the   plane  surface  of    the 

*//  bones  of  the  leg.     Fig.  402  represents  a  foot 

after  recovery  upon  which  I  did  this  opera- 
tion in  1885. 

The  Shoulder- Joint. — Exsection  of  the 
head  of  the  humerus  is  readily  effected  by 
a  single  straight  incision,  about  five  inches 
in  length,  made  from  the  acromion  process 
directly  down  the  arm,  parallel  with  and 
splittiug  the  fibers  of  the  deltoid  (Fig.  403). 
The  periosteum  should  be  carefully  lifted  as 
far  as  the  ostitis  extends,  and  the  soft  tis- 
sues about  the  capsule  raised  with  the  ele- 
vator. The  edges  of  the  wound  should  be 
held  wide  apart  by  blunt  retractors,  and  the 
tendons  of  insertion  of  the  supra  and  infra 
spinatus,  teres  minor,  and  subscapularis  di- 


Fio.  403. 


368 


A  TEXT-BOOK   ON   SURGERY. 


Fio.  404. — Lonffitudinal  section  tlirnufh  tlie  shoulder-i"int, 
showing  the  relations  of  the  bones,  li^jainents,  and  niuH- 
cles  immediately  about  the  articulation.  1,  The  capsu- 
lar ligament.  2,  The  acromion.  3,  Epiphysis.  (Alter 
Braune. ) 


vided  close  to  the  tuberosities  with  the  curved  blunt  scissors.  The  sheath 
for  the  long  head  of  the  biceps  should  be  laid  open,  and  this  tendon  held 
aside.  If  the  exsector  is  used,  tlie  bone  should  now  be  divided  at  the 
limit  of   the  disease.     ^Vllen  the  section   is   completed  a  strong  hook 

should  be  fastened  into  the 
end  of  the  upper  fragment, 
in  order  to  lift  it  and  facili- 
tate the  separation  of  the  soft 
tissues  on  the  inner  and  un- 
der surface  from  tlie  bone  and 
capsule.  The  capsular  liga- 
ment should  be  trimmed  from 
the  margins  of  (he  glenoid 
cavity  and  removed  with  the 
head  of  the  humerus.  All 
diseased  tissues  should  be 
dissected  out  with  the  curved 
scissors,  and,  if  the  head  of 
the  scapula  is  involved,  all 
disorganized  bone  should  be 
scraped  away  with  the  spoon 
or  rongeur.  If  the  exsector  can  not  be  had,  the  capsule  should  be  di- 
vided and  the  head  of  the  bone  dislocated  upward  through  the  wound. 
The  division  is  then  made  with  a  narrow  saw,  taking  the  precaution  to 
protect  the  soft  parts  from  injury.  Upon  examining  the  wound  left 
after  this  operation,  it  will  be  seen  that  the  deepest  portion  is  behind  and 
to  the  outer  side  of  the  end  of  the  shaft.  Into  this  depression  carry  a 
closed  dressing-forceps,  and  bore  through  to  the  skin,  pointing  the  in- 
strument to  the  inferior  and  outer  asi)ect  of  the  arm.  Divide  the  skin 
over  the  point  of  the  forceps,  dilate  the  opening  by  separation  of  the 
handles,  and  draw  a  drainage-tube  from  below  upward  through  the  hole. 
A  second  shorter  tube  should  make  its  exit  through  the  anterior  and 
lower  angle  of  the  wound  of  incision,  and  the  wound  closed  throughout 
with  catgut.  The  forearm  should  be  held  in  a  sling  or  fastened  across 
the  abdomen.  The  application  of  Esmarch's  bandage,  and  the  rubber 
tubing  in  the  axilla  and  over  the  clavicle  and  scapula,  renders  this  oper- 
ation practically  bloodless.  The  rate  of  mortality  is  exceedingly  low. 
AVith  careful  antisepsis  it 
is  practically  without  dan- 
ger to  life.  A  second  ojier- 
ation  for  the  removal  of 
dead  bone  is  occasionally 
required. 

TheM.how-Jomt.-Yla-s. 
the  forearm  on  the  arm  and 
make  a  straight  incision, 

commencing  in  the  middle  of  the  posterior  aspect  of  the  humerus,  about 
one  inch  above  the  condyles,  and  extending  over  the  center  of  the  olec- 


FiG.  405. 


EXSECTIONS   OF   THE   JOINTS. 


369 


ranon  process,  along  the  ulnar,  for  fmni  two  to  three  inches  (Fig.  405). 
The  tissues  should  be  carefully  lifted  from  the  bone  and  capsule,  and 
held  to  either  side  by  blunt  retractoi's.  When  the  trough  between  the 
olecranon  and  interiinl  condyle  is  approached,  extra  care  should  be  taken 
not  to  wound  the  ulnar  nerve,  which  passes  in  this  groove.  It  may  be 
avoided  by  keeping  close  to  the  bones  with  the  knife  or  elevator.  After 
the  posterior  ligament  is  divided,  the  olecranon  may  be  displaced,  and, 
if  involved  in  the  destructive  ostitis,  may  now  be  sawn  off  in  order  to 
facilitate  the  operation.  The  articular  end  of  the  humerus  should  be 
exposed,  as  high  as  the  point  of  section,  by  peeling  off  the  soft  tissues 
with  the  periosteum,  after  which  a  retractor  is  applied  and  the  bone 
divided  with  a  Butcher's  saw  or  the  exsector.  Tliis  line  of  section  should 
be  at  an  angle  of  90°  to  the  shaft  of  the  humerus.  The  ends  of  the  ulna 
and  radius  may  now  be  readily  displaced  backward,  exposed  to  the  point 
of  section,  and  divided  on  a  line  parallel  with  that  through  the  humerus. 


t;/i»' 


Fio.  406. — Longitudinal  section   tlirouo-h   the  elbow-joint.     1,  Kadial  nerve.     Superficially  on  the  fle.xor 
surtiice  the  median  basilic  vein  is  seen  cut  acro-sa.     (After  Braune.) 

As  in  all  the  joint  exsections,  a  careful  dissection  of  all  the  diseased  cap- 
sule and  soft  parts  must  be  made.  The  wound  is  drained  from  the  mo.st 
dependent  portion,  and  closed  with  catgut  sutures.  An  anterior  splint, 
previously  fitted  to  the  arm  and  forearm,  and  fashioned  so  as  to  hold  the 
forearm  half  way  between  flexion  at  a  right  angle  and  complete  extension, 
is  wrapped  with  gauze  and  laid  on  the  anterior  aspect  of  the  extremity, 
and  fixed  by  a  roller  to  the  arm  and  forearm,  to  within  a  few  inches  of 
the  incision.  A  sublimate  dressing  is  next  applied  to  the  wound,  with 
cotton  and  protective,  and  a  bandage  over  this  to  effect  compression  and 
to  hold  it  in  position.  Wlien  a  change  of  dressing  is  required,  this  last 
bandage  only  is  removed.  The  rule  in  this  exsection  is  fibrous  anchylosis, 
with  limited  motion  of  the  joint  and  function  of  the  extremity. 

Exsection  of  the  elbow  is  not  a  dangerous  procedure,  and,  although 
not  usually  attended  with  the  success  which  follows  some  other  opera- 
Si 


370 


A  TEXT-BOOK   OX  SURGERY. 


tions  (as  those  upon  the  shoulder  and  ankle),  it  should  be  preferred  to 
amiMitation.    The  anatomical  relations  at  this  joint  are  shown  in  Fig.  40G. 
The  Wrist -Joint. — The  exsection  of  this  joint  is  attended  with  con- 
siderable difficulty,  not  only  in  the  performance  of  the  opeiation,  but  in 


Fig.  407. — Bourcfery's  operation  (modified). 


Fio.  408.— Lanpeiibcclv's  incision.     (Allir  Esmarcb.) 


the  after-treatment.  Moreover,  it  is  more  apt  to  be  followed  by  failure, 
resulting-  in  amputation.  Of  the  two  procedures — viz.,  the  double  lateral 
and  parallel  inci-sions  (Fig.  407),  and  the  single  longitudinal  dor.sal  incision 
(Fig.  408) — the  latter  is  preferable  when  the  destructive  pi'ocess  is  not  so 
extensive,  and  when  the  sjjoon  or  gouge  may  be  used,  while  the  foi-mer 
will  give  the  freest  access  to  the  bones  when  the  saw  or  exsector  is  to 


Fio,  403. — EsmarL-h's  lutuiTUijtud  splint  for  exsection  of  the  wrist. 

be  employed  in  the  removal  of  a  large  portion  of  the  bones  which  enter 
into  the  composition  of  this  joint. 


EXSECTIOXS   OF   THE  JOINTS. 


371 


Fig.  410. — TLe  same  applied. 


lu  the  operation  v.itli  a  single  dor- 
sal inci.3ion  the  wrist  should  be  made 
prominent,  by  flexing  the  hand  on  the 
foreai-m,  and  the  integument  divided 
along  the  tendon  of  the  extensor  com- 
munis digitorum,  which  goes  to  the 
index  -  finger,  the  incision  extending 
from  the  middle  of  the  metacarpus  to 
one  inch  and  a  half  above  the  tip  of 
the  styloid  processes.  The  tendon  may 
be  retracted  to  the  side  most  conven- 
ient. The  i^osterior  segment  of  the  an- 
nular ligament  is  divided,  and  the  tis- 
sues lifted  from  the  bones  with  the 
elevator.  The  end  of  the  radius  should 
be  removed  with  the  exsector  or  gouge,- 
when  the  carpus  may  be  displaced 
backward  through  the  incision,  and 
removed  wholly  or  in  jjieces.  When 
the  section  is  completed,  the  surfaces 
should  be  brought  in  apposition  and 
fixed  upon  a  well-adjusted  anterior 
splint.  Or  an  inten-uj^ted  dressing  may 
be  applied  by  incasing  the  forearm  in 
jilaster  of  Paris  to  within  an  inch  of 
the  incision,  and  the  fingers  and  hand 
in  the  same  material,  back  as  far  as 
the  anterior  limit  of  the  wound.  A 
piece  of  hoop-iron  (or  several  pieces 
of  telegraph-wire  twisted  into  a  single 
piece)  is  shaped  as  shown  in  Fig.  409, 
incorporated  into  the  plaster  upon  the 
arm,  and  made  to  loop  over  the  wrist 
to  the  tips  of  the  fingers,  where  it  is 
turned  back  underneath  the  hand,  and 
is  fastened  to  the  plaster  here  by  an 
additional  gypsum  liandage  (Fig.  410). 

In  the  other  operation  one  incision 


372  A  TEXT-BOOK   ON   SURGERY. 

is  made  along  tlie  outer  and  dorsal  aspect  of  the  metacarpal  l)one  of  the 
little  finger,  over  the  styloid  of  the  ulna,  and  one  inch  along  this  bone. 
The  radial  incision  should  coiunience  on  the  dorsum  of  the  metacarpal 
bone  of  the  index-tinger,  jjass  backward  and  slightly  toward  the  radial 
surface  of  the  forearm  to  a  point  half  an  inch  above  the  tip  of  the  styloid 
process,  and  thence  directly  ui^ward  along  the  dorsal  aspect  of  the  radius. 
In  extensive  operations  it  may  become  necessary  to  divide  the  tendon  of 
the  extensor  ossis  metacarpi  pollicis,  which  is  crossed  by  the  incision. 
When  done,  the  ends  should  be  reunited  l)y  silk  sutui'es  when  the  f>per- 
ation  is  finished.  The  tissues  are  lifted  from  the  bones  and  capsule  as 
before,  and  the  sections  made  with  the  exsector  or  key-hole  saw. 


CHAPTER  XIV. 

REGIONAL   SURGERY. — THE   HEAD. 

Tumors  of  the  Scalp. — The  most  common  tumors  of  the  scalp  are 
cysts.     They  are  congenital  and  acquired. 

Congenital  cysts  are  rare  as  compared  with  the  acquired.  They  are 
deeply  situated,  being  beneath  the  skin,  and  not  infrequently  below  the 
fascia  and  muscles.  Their  contents  are  chiefly  white  or  yellow  fluid,  and 
at  times  hairs.  Each  tumor  may  consist  of  a  single  cyst,  or  there  may  be 
several  grouped  together  (multilocular),  the  mass  rarely  attaining  a  size 
greater  than  an  inch  in  diameter.  If  left  alone  they  may  ulcerate  from 
pressure  or  injury,  or,  in  rare  instances,  may  cause  atrophy  and  perfora- 
tion of  the  calvaria  and  dura  mater.  They  should  be  removed  in  early 
childhood.  The  operation  consists  in  dissecting  oiit  the  sac,  with  its 
contents.  As  a  rule,  small  wounds  of  the  scalp,  situated  where  a  scar 
will  not  be  apparent,  do  not  need  to  be  stitched.  The  edges  should  be 
approximated  and  held  thus  by  a  dressing  of  sublimate  gauze  and  a 
bandage. 

Acquired  cysts,  commonly  called  "  wens,"  are  of  two  varieties,  one 
due  to  retention  of  sebum  in  a  sebaceoiis  follicle,  the  duct  of  which  has 
been  obstructed  ;  the  other  caused  by  extravasation  of  blood,  where  the 
clot  has  been  absorbed,  leaving  the  serum  more  or  less  stained  by  the 
decomposition  of  hsematin.  They  are  round,  smooth  tumors,  are  super- 
ficial, and  found  most  frequently  upon  the  upper  and  posterior  portion 
of  the  scalp.  They  are  mostly  multiple,  are  unilocular,  and  contain  a 
granular,  cheesy  substance.  The  treatment  is  removal  with  the  knife. 
The  hair  should  be  shaved  from  the  tumor,  and  for  a  slight  distance  be- 
yond its  base.  Complete  anaesthesia  can  be  obtained  by  injecting  about 
TT,  XX  of  a  2-per-cent  solution  of  cocaine  in  the  line  of  incision,  and  around 
the  base  of  the  tumor.  With  a  sharp  bistoury  transfix  the  mass  through 
its  base,  and  lay  it  open.  The  integument  over  the  center  of  the  tumor 
will  be  found  exceedingly  thin  (not  thicker  than  ordinary  writing-paper), 
and  may  be  easily  separated  from  the  thickened  sac,  Avhich  should  now 
be  seized  with  a  strong  pair  of  forceps  and  torn  out  of  its  bed.  If  any 
strong  adhesions  are  found  they  should  be  divided  with  the  blunt 
scissors. 

Sebaceous  cysts  occasionally  become  inflamed,  the  capsule  breaks 
down,  the  contents  escape,  and  a  mass  of  granulation-tissue  replaces  the 
original  tumor.    The  new-formed  capillaries  in  this  tissue  frequently  give 


374  A  TEXT-lJpOK   OX   SURGERY. 

way,  causing  repeated  li;cinoirlui,u'e.  They  .should  l)e  seraped  out  with  u 
sharp  spoon,  and  the  sac  removed  by  dissection. 

Horns,  or  dense  ei)itlielial  outgrowths,  are  t>ccasionally  seen  upon  tlie 
scalp  and  face.  Some  of  these  excrescences  attain  hirge  size,  Tliey 
should  be  removed  by  an  elliptical  incision  around  the  point  of  attach- 
ment. Tlie  incision  slioidd  remove  the  entire  thickness  of  the  integu- 
ment. 

Lipomata.,  or  fatty  tumoi's,  are  of  infrequent  occurrence  beneath  I  la- 
scalp,  and,  on  account  of  the  dense  integument,  they  grow  very  slowly, 
and  rarely  attain  large  size.  The  diagnosis  between  sebaceous  and  fatty 
tumors  of  this  region  is  not  always  easy.  The  treatment  is  removal  by 
dissection,  which  is  easily  effected  by  lifting  the  tunioi'  from  its  cap- 
sule with  the  finger  or  the  blunt  scissors.  The  capsule  need  not  be  re- 
moved. 

JVcBDt,  porf-wine  marJcs,  and  other  vascular  tumors,  are  quite 
comnion  upon  the  seal]).  Tiiey  have  been  treated  of  in  a  previous 
chaiiter. 

Papillomata,  or  warts,  occasionally  covering  a  large  territory,  are 
found  in  this  region.  In  one  case  which  came  under  my  care  a  flat  y>n])il- 
lonui,  two  inches  in  width,  extended  from  the  right  temple  to  the  middle 
line  of  the  scalp.  They  should  be  clipped  closely  with  the  curved  scis- 
sors, their  bases  bui-ned  with  the  actual  cautery  or  nitric  acid,  and  the 
operation  repeated  until  a  cure  is  effected. 

Elephantiasis,  or  general  thickening  of  the  scalp  from  connective- 
tissue  new-formation,  is,  fortunately,  rarely  met  with.  Ligation  of  the 
vessels  feeding  the  diseased  area  will  afford  temporary  relief,  and  is  a 
justifiable  procedure. 

JRcinafoma  has  been  considered  in  the  chapter  on  Wounds  of  the 
Scalp. 

Abscess  of  the  scalp  requires  free  incision,  irrigation,  and  drainage. 
Any  doiibts  as  to  the  character  of  the  swelling  may  be  dissipated  by  ex- 
ploration Avith  the  hypodermic  syringe  and  a.  good-sized  needle. 

Pneumatocele,  or  "rt7>-^;f??ior,"  is  occasicmally  met  with  beneath  the 
scalp.  It  results  from  disease  or  fracture  of  some  of  the  bones,  permit- 
ting communication  with  the  cavities,  as  the  frontal  sinus,  or  the  Eusta- 
chian tube,  etc.,  and  the  escape  of  air  beneath  the  skin.  Evacuation  of 
the  contents  by  pressure,  with  or  withoiit  puncture,  and  a  compress  to 
prevent  recurrence,  will  produce  inflammatory  adhesions  and  cause  a 
cure. 

Ostitis,  or  periostitis,  is  not  uncommon  in  the  calvaria.  The  causes 
are  the  same  as  for  ostitis  elsewhere.  Great  care  should  be  observed  in 
the  treatment,  on  account  of  the  proximity  of  the  meninges  and  brain. 
Ostitis  with  exfoliation  demands  early  recognition  and  immediate  opera- 
tive interference.  A  free  horseshoe  or  crucial  incisicm  should  be  made, 
ami  all  the  diseased  bone  removed  with  the  sharp  spoon.  When  the 
exfoliation  is  confined  to  the  outer  table  of  the  skull  the  prognosis  is 
favorable.  The  wound  should  be  kept  open,  well  drained,  and  allowed 
to  heal  by  granulation.     If  pus  is  found  beneath  the  inner  table,  enough 


REGIONAL  SURGERY.— THE   HEAD. 


375 


of  the  bone  should  ))e  cut  away  with  the  rongeur  to  permit  the  free 
escape  of  all  of  the  products  of  inflammation.  The  jiatient  should  be 
required  to  rest  in  the  position  which  secui'es  most  perfect  drainage.  A 
loose  antiseptic  dressing  should  be  applied. 

Osteoma,  or  exostosis,  occurs  quite  frequently  upon  the  bones  of  the 
skull.  "When  not  due  to  syphilis  they  should  be  removed  eai'lj",  by  the 
gouge  or  chisel,  as  there  is  always  danger  of  pressure  uj^on  important 
organs  if  allowed  to  remain.  Syphilitic  hyperostosis  requires  the  specific 
treatment  given  for  this  dyscrasia. 

Encephalocete,  or  ?ieruia  cerebri,  is  a  protrusion  of  the  brain-substance 
through  an  opening  in  the  calvaria.  This  condition  usually  occurs  in 
children  suffei'ing  from  liyfl roceplialus,  the  protrusion  taking  place 
through  the  abnormally  enlarged  fontanelles.  The  dura  mater  sur- 
rounds and  is  carried  in  front  of  the  mass,  lying  in  contact  with  the  peri- 
cranium. When  the  meninges  alone  protrude,  the  tumor  is  known  as  a 
meningocele. 

Hernia  cerebri  may  occur  after  perforation  of  the  skull  from  any 
cause,  as  fracture  or  necrosis.  More  fre- 
quently the  mass  which  protrudes  is  made 
up  of  a  granulation-tissue  containing  no  ele- 
ments from  the  brain-substance,  while  at 
times  these  masses  are  composed  of  both 
brain-  and  granulation-tissue  (Fig.  412).  The 
character  of  the  tumor  will  be  recognized 
from  its  rapid  development  after  perforation 
of  the  calvaria. 

Treatment. — AVhen  the  mass  is  small,  and 
is  just  beginning  to  project,  compi-essii )n 
should  be  employed  to  prevent  a  further 
protrusion.  It  is  not  safe  to  attempt  a  re- 
duction of  the  tumor.  The  hair  should  be 
shaved  from  tlie  scalp  near  the  opening  and 
disinfection  accomplished  by  sublimate  irri- 
gation, and  a  compress  of  sublimate  gauze 
and  absorbent  cotton  applied.     If  the  tumor 

does  not  rapidly  slough  away,  it  should  be  removed  at  the  level  of  the 
scalp  with  the  elastic  ligature  or  the  actual  cautery. 

Sarcoma  of  the  dura  mater  is  a  grave  condition,  fortunately  of  infre- 
quent occurrence.  In  the  process  of  development  the  tumor  is  aj)t  to 
cause  absorption  of  the  calvaria,  and  finally  perfoi-ation.  This  iisu- 
ally  occurs  long  after  symptcmis  of  pressure  from  witliin  have  been  de- 
velojied.  If  the  patient  sui-vive  the  compression  of  the  brain,  the  tumor 
ultimately  undergoes  necrosis  and  breaks  down  into  a  dirty  mass,  in 
which  the  process  of  ulceration  is  accompanied  by  frequent  haemorrhage. 

Carcinoma  of  the  meninges  may  occur  as  a  result  of  metastasis,  al- 
though rarely  if  ever  occurring  primarily  in  this  situation. 

In  sarcoma  and  carcinoma  of  the  dura  mater  little  more  can  be  done 
than  to  relieve  pain  by  the  employment  of  narcotics. 


Flo.  41'2. — .\Ia>s  C'liiiiK.si'il  of  brain- 
substiinc'c  ami  fjriiuulatioii-tissue, 
removed  by  Dr.  E.  .1.  Beall  from 
a  boy  whose  skull  had  been  fract- 
ured.    Exact  size. 


376  A  TEXT-BOOK  ON  SURGERY. 

Hydroeepkalus  is  i)nniaiily  a  disease  of  the  arachnoid  and  pia 
nutter.  It  is  a  disease  of  childhood,  resultinff  from  inherited  tubercu- 
losis. Tiie  gross  lesion  is  a  transudation  of  a  serous  fluid  from  the  i)ia 
and  arachnoid  into  the  cavities  of  the  ventricles,  the  arachnoid,  and  sid)- 
arachnoid  spaces.  Distention  of  the  ventricles,  compression  of  the  brain- 
substance,  se]«iration  of  the  sutures,  enlargement  and  deformity  of  the 
head,  projection  of  the  eyeballs,  downward  squint,  and  loss  of  cerebral 
function,  are  the  symjitoms,  invariably  ending  in  death. 

Treatment. — Tapping  will  at  times  relieve  the  more  urgent  symp- 
toms of  distention  and  compression.  Careful  antisei)sis  should  be  prac- 
ticed, and  the  aspiration  made  through  one  of  the  lateral  angles  of  the 
anterior  fontanella.  A  small  needle  should  be  introduced,  ami  three 
or  four  ounces  slowly  withdrawn,  the  operation  occujiying  froui  fifteen 
to  thirty  minutes.  This  treatment  is  palliative,  and  is  only  justifi- 
able in  the  effort  to  relieve  the  suffering  of  the  patient.  A  cure  is 
impossible. 

Wounds  of  the  scalp  should  be  treated  as  wounds  of  other  parts  of 
the  integument.  Incised  wounds  should  be  rendered  aseptic,  and  may 
be  closed  by  sutures,  or  the  edges  brought  into  apposition  by  a  sublimate- 
gauze  compress  and  bandage,  according  to  the  extent  and  location  of  the 
injury.  Sutures  are  as  well  tolerated  here  as  elsewhere.  When  there  is 
no  especial  desire  to  avoid  a  scar,  sutures  may  be  omitted,  unless  the  wound 
is  so  extensive  and  gaping  that  apposition  can  not  be  effected  by  com- 
pression. Silk  is  preferalde  in  stitching  wounds  of  the  scalp.  Tlie  hair 
should  be  trimmed  for  a  fourth  or  half  inch  from  the  edges  of  the  wound. 
When  no  large  vessels  have  been  divided,  the  introduction  of  the  sutures 
will  suffice  to  arrest  the  bleeding.  It  is  a  safe  precaution  to  insert  a  small 
twist  of  catgut  into  one  angle  of  the  wound  to  .secure  drainage  in  case  of 
suppuration. 

Lacerated  wounds  of  the  scalp  are  at  times  very  extensive  and  for- 
midable. Several  instances  are  reported  of  complete  avulsion  of  the 
female  scalp  from  the  entanglement  of  the  hair  in  machinery.  In  such 
cases  transplantation  of  integument  becomes  necessary,  in  order  to  pre- 
vent ostitis  from  denudation  of  the  calvaria.  Ordinary  lacerated  wounds 
should  be  rendered  aseptic,  and  treated  by  a  compress  of  sublimate 
gauze.  No  sutures  should  be  employed,  excej:)!  when  a  scar  is  to 
be  avoided,  and  then  only  after  the  torn  and  bruised  edges  have  l)een 
trimmed  off  with  the  scissors. 

Contused  wounds  of  the  scalp  are  usually  followed  by  marked  swell- 
ing, due  to  extravasation  of  blood  (ha^matoma)  beneath  the  pericranium. 
The  treatment  consists  in  cold  applications,  by  means  of  the  ice-bag  or 
cloths  taken  from  ice-water.  If  suppuration  occurs,  incision  should  be 
promptly  made.  A  form  of  serous  cyst  sometimes  results  from  haema- 
toma  of  the  scalp.  It  should  be  treated  by  aspiration,  and,  if  one  or  two 
evacuations  do  not  effect  a  cure,  it  should  be  incised,  and  the  cyst-wall 
dissected  out. 

Gunshot  wounds  in  this  part  require  no  especial  conisideration. 

Punctured  wounds  of  the  scalp  are  not  serious,  as  a  rule,  when  no 


REGIONAL  SURGERY.— THE   HEAD.  377 

poison  is  introduced  through  the  wound,  and  when  the  bones  are  not 
penetrated. 

Penetrating  Wounds  of  the  Skull. — \Vhen  a  foreign  body  has  pene- 
trated the  cranial  cavity  and  passed  ont,  and  the  patient  survives  the  im- 
mediate effect  of  the  accident,  the  wounds  of  entrance  and  exit  should  be 
cleansed  of  loose  fragments  of  bone,  or  any  foreign  body.  To  accomplish 
this  it  will  be  not  only  justifiable,  but  often  imperative,  to  enlarge  both 
openings,  by  use  of  the  trephine,  and,  while  employing  strict  antiseptic 
precautions,  to  secure  free  drainage  for  the  discharge  of  blood  or  other 
fluids  from  the  track  of  the  missile.  When  severe  intra-cranial  haemor- 
rhage occurs,  no  attemi)t  should  be  made  to  arrest  it  by  plugging  the 
wounds  through  the  skull,  for  fatal  compression  of  the  brain  might  thus 
result.  If  the  vessels  involved  can  not  be  reached  from  the  enlarged 
openings,  and  secured  by  haemostatic  forceps  or  the  ligature,  the  head  of 
the  patient  should  be  elevated,  in  order  to  diminish  the  pressure  at  the 
bleeding  point.  This  may  in  part  be  aided  by  ligation  of  the  extremi- 
ties, as  heretofore  described. 

If  there  is  only  a  single  opening,  and  the  body  is  lodged  within  the 
cranium,  a  careful  inspection  should  be  made  about  the  wound  of  en- 
trance, and,  if  the  presence  of  the  missile  can  be  recognized,  it  should  be 
at  once  extracted,  even  if  the  ajiplication  of  the  trephine  is  required.  If 
the  bullet  shall  have  entered  the  substance  of  the  brain — which  can  be 
determined  in  jjart  by  the  careful  employment  of  a  light  Nelaton's  probe, 
jsrovided  with  a  good-sized  porcelain  tip,  introduced  through  the  wound  in 
the  skull,  sufficiently  enlarged  by  the  trephine— the  probabilities  are  that 
it  has  passed  through  the  brain  in  the  line  of  projection  of  the  missile, 
and  is  lodged  beneath  the  skull,  at  or  near  a  point  directly  in  the  line  of 
its  projection.  This  condition  was  found  to  exist  in  the  remarkable  case 
operated  on  by  Prof.  "W.  F.  Fluhrer,  in  Belle- 
vue  Hospital,  in  1884.     The  patient,  aged  nine-  /''TTT^ 

teen  years,  received  a  pistol-shot  wound,  enter-  /  \ 

ing  at  the   forehead  and   passing  through  the  /^        _^       J 

brain,  in  the  line  shown  in  Fig.  413.     The  hole  V'        }y     / 

of  entrance  was  enlarged  by  biting  off  the  edges  y         '       7 

of    the    bone    with  a    rongeur.      An    alarmino-  ^^     ^^?^^\ 

haemorrhage  from  a  vessel  of  the  pia  mater  was  y/t^^  y^  ^ 

controlled  by  a  small  artery-clamp,  or  forceps.  /    l^_S>'^~''^  \ 

The  i:)atient's  head  was  placed  so  that  tlie  sup-       //  h  !^ 

posed  track  to  be  explored  was  perpendicular     '    /  ' 

to  the  surface  of  the  table.  A  good-sized  por-  fic.  ^s.-Fiuiircr'scaseofpenc- 
celain-pomted  Xelaton's  probe  was  carefully  in-  [heL^inlur'tArtorFiuilf) 
troduced,  and  allowed  almost  to  find  its  o^vn 

way  in  the  track  left  by  the  bullet.  This  instrument  passed  to  a  depth 
of  six  inches,  where,  a  slight  resistance  being  met  ^vith,  it  was  allowed 
to  remain.  The  direction  of  the  probe  indicated  the  point  on  the  oppo- 
site side  of  the  skull,  at  which  the  missile  had  most  i)robab]y  struck. 
Three  fourths  of  an  inch  below  this  line  the  trephine  was  applied.  Upon 
removing  the  disk  of  bone  the  dura  mater  appeared  dark  from  blood 


378 


A  TEXT-BOOK   ON  SURGERY. 


effused  beneath  it.  An  incision  was  made  through  this,  and  the  traok  of 
the  bullet  through  the  pia  mater  was  discovered.  It  had  struck  the  iiuici- 
surface  of  the  calvarin,  had  ivbounded  with  a  downward  dellection,  and 
was  found  about  half  an  inch  from  the  hole  made  by  the  trephine.  A 
small  rubber  drainage-tube  was  passed  entirely  through  the  track  made 
by  the  bullet,  and  left  ])i'ojecting  at  each  opening.  Irrigation  through 
the  tube  was  not  attempted.  The  wounds  were  dressed  with  iodoform- 
ized  gauze,  loosely  laid  on,  and  an  antiseptic  dressing  over  this.  The 
patient  recovered  and  returned  to  his  occu]iation,  suffering  only  with  a 
slight  impairment  of  memory  and  occasional  muscular  spasm. 

The  important  lesson  from  this  case  is,  that  the  careful  exploration  of 
the  cranial  cavity,  and  of  the  brain-substance,  for  the  removal  of  a  foreign 
body,  is  a  rational  and  justifiable  surgical  procedure.  The  careful  em- 
ployment of  a  light,  broad,  dull-pointed  prol)e  will  enable  the  operator, 
in  a  certain  proportion  of  cases,  to  follow  in  the  track  of  a  foreign  ])ody 
and  indicate  its  place  of  lodgment. 

Not  infrequently  compression  of  the  brain  occurs  from  hjemorrhage 
between  the  skull  and  the  dura  mater,  or  from  a  collection  of  pus,  exos- 
tosis, depression  of  bone,  or  tumor  within  the  cranium.  "Within  recent 
years  researches  in  cerebral  anatomy  and  phjsiology  have  enabled  scien- 
tists to  determine,  with  accuracy  sufficient  to  justify  the  application  of 
their  conclusions  to  sxirgical  practice,  from  the  disturbance  of  function 
in  certain  portions  of  the  economy,  the  region  of  the  brain  involved  in 
the  zone  of -compression.     That  portion  of  this  subject  which  is  most 


Fissure  of  Rolando.    Fissure  of  Sylvius. 


Fig.  414.— (llodified  .qftcr  Cbampionnierc.) 

capable  of  demonstration,  and  therefore  most  practical,  relates  to  the 
interference  with  motion  in  certain  muscles,  or  groups  of  muscles,  which 
have  their  "centers  of  motion"  situated  contiguous  to  the  fissure  of 


REGIOXAL   SURGERY.— THE   HEAD.  379 

Rolando,  and  to  certain  disturbances  of  the  mind  and  the  senses  chiefly 
located  in  the  cortex  of  the  brain.  According  to  Lucas-Championniere,* 
who  adopts  the  conclusions  of  Charcot  and  Pitres,  our  knowledge  of  this 
subject  may  be  summarized  as  follows :  "  In  a  lesion  followed  by  paraly- 
sis of  the  lower  extremity  the  trephine  should  expose  the  summit  of  the 
ascending  jyarietal  convolution,  on  both  sides  of  the  upper  end  of  the 
fissure  of  Rolando  (Fig.  414).  Of  the  upper  extremity,  the  middle  third 
of  the  ascending  frontal  convolution,  also  on  both  sides  of  the  center  of 
the  fissure  ;  vpper  and  loioer  extremities,  both  regions  just  given  ;  upper 
extremity  alone,  with  motor  aphasia,  foot  of  tJiird  frontal  and  lower 
third  of  ascending  frontal  convolutions,  in  zone  marked  motor  aphasia 
in  Fig.  414.  Facial  paralysis,  lower  third  of  the  ascending  frontal 
and  foot  of  second  frontal  convolutions.  Aphasia  alone,  foot  of  third 
frontal.'''' 

After  a  careful  analysis  of  all  the  cases  of  cortical  lesions  of  the  brain 
published  in  America,  and  a  thorough  review  of  the  results  of  foreign 
Investigators,  Prof.  Starr  arrives  at  the  following  conclusions  :  f 

"1.  Various  powers  of  the  mind  are  to  be  connected  with  activity  in 
various  regions  of  the  biain,  the  surface  of  the  organ  being  the  seat  of 
conscious  mental  action. 

"2.  The  highest  qualities  of  the  mind — intellect,  judgment,  reason, 
self-control — require  for  their  normal  display  integrity  of  the  entii'e  brain, 
but  especially  of  the  frontal  lobes.  A  change  of  disj^osition  and  charac- 
ter may  be  considered  as  symptomatic  of  disease  of  the  brain,  and,  in  the 
absence  of  other  symptoms,  of  disease  of  the  frontal  lobes. 

"3.  The  power  of  sensory  perception  is  distributed  over  the  various 
regions  of  the  brain  ^ith  which  the  various  sensory  organs  are  anatomic- 
ally connected.  In  these  regions  objects  are  not  only  first  consciously 
perceived,  but  are  also  subsequently  recognized  ;  and  hence  it  is  in  these 
regions  that  the  memory  pictures  are  stored,  by  whose  aid  the  act  of 
recognition  is  accomplished. 

"  («)  Disturbance  of  sight,  whether  in  the  form  of  actual  blindness, 
or  of  failure  to  recognize  or  to  remember  familiar  objects,  or  of  hallucina- 
tions of  vision,  may  indicate  disease  in  the  occipital  lobes.  An  examina- 
tion of  the  field  of  vision  will  indicate  which  lobe  is  affected,  since  blind- 
ness in  the  right  half  of  both  eyes  may  be  due  to  destx'uction  of  the  left 
lobe,  and  l)lindness  of  the  left  half  of  both  eyes  may  be  due  to  destruction 
of  the  right  lobe. 

"  (6)  Disturbance  of  hearing,  either  actual  deafness  in  one  ear  or  hal- 
lucinations of  sound  on  one  side  (voices,  music,  etc.),  may  indicate  disease 
in  the  first  temporal  convolution  of  the  opposite  side.  Failure  to  recog- 
nize or  to  remember  spoken  language  is  characteristic  of  disease  in  the 
first  temporal  convolution  of  the  left  side  in  right-handed  persons,  and 
of  the  right  side  in  left-handed  persons.     Failure  to  recognize  printed  or 

*  "  La  trepanation  guiJue  par  lis  localisations  cerebrales."  V.  A.  Delahaye  ct  Cie.,  Paris, 
18V8. 

t  "  Cortical  Lesions  of  the  Brain."  M.  Allen  Starr,  from  "American  Journal  of  the  Medi- 
cal Sciences,"  July,  188-t. 


380  A  TEXT-BOOK   ON   SURGERY. 

HTitten  language  has  accompanied  disease  of  the  angular  gyrus  at  the 
junction  of  the  teniiioral  and  occipital  regions  of  the  left  side  in  three 
foreign  and  in  one  American  case. 

"  (c)  Disturbance  of  smell,  either  as  an  hallucination  or  as  a  loss  of 
power  to  perceive  odors,  may  possibly  indicate  disease  in  the  temporo- 
sphenoidal  region  on  the  base  of  the  brain. 

"(fZ)  Disturbance  of  taste  can  not,  as  yet,  be  connected  with  disease 
in  any  region.  This  is  due  to  lack  of  care  in  testing  this  sense  in  cases 
of  brain  disease. 

"  (e)  Disturbance  of  general  sensation — including  the  senses  of  touch, 
pressure,  pain,  and  temperature,  together  with  the  sense  of  the  location 
of  a  limb — may  occur  either  in  the  form  of  subjective  perceptions  of  such 
sensations  without  objective  cause,  or  in  the  form  of  impairment  of  these 
sensations.  In  either  case  it  indicates  a  disease  in  the  central  convolu- 
tions, and  possibly  in  the  adjacent  i)ortion  of  tlie  parietal  lobules. 

"  4.  The  power  of  voluntary  motion  of  the  muscles  of  tlie  opposite  side 
of  the  body  is  located  in  the  two  central  convolutions  which  border  the 
fissure  of  Rolando.  Motions  of  the  face  and  tongue  originate  in  the  lower 
thml  of  this  region  ;  motions  of  the  arm,  in  the  middle  third  ;  motions  of 
the  leg,  in  the  upper  third. 

"  Spasms  in  a  single  group  of  muscles,  or  paralysis  of  a  single  group  of 
muscles,  may  indicate  disease  of  its  motor  area.  Extensive  spasms  or 
paralysis  may  indicate  a  large  area  of  disease  in  this  region  ;  but  if  more 
marked  in  a  single  group  of  muscles  than  in  others  it  may  indicate  a  small 
focus  of  disease  in  the  motor  area  of  that  group  affecting  other  motor 
areas  indirectly  and  coincidently.  Paralysis  following  spasm  in  one 
group  of  muscles  is  a  characteristic  symptom  of  disease  in  the  central 
region. 

"  5.  Disturbance  of  the  power  of  speech  indicates  disease  in  the  convo- 
lutions about  the  fissure  of  Sylvius,  on  the  left  side  in  right-handed  persons, 
and  on  the  right  side  in  left-handed  persons.  If  the  i:)atient  can  under- 
stand a  question  and  can  recall  the  words  needed  for  a  reply,  but  is  un- 
able to  initiate  the  necessary  motions  involved  in  speaking,  the  disease  is 
jn'obably  in  the  third  frontal  convolution,  and  in  the  adjacent  portion  of 
tlie  anterior  central  convolution.  If  the  patient  can  not  recognize  spoken 
language,  but  can  repeat  words  after  another,  or  can  use  exclamations 
on  being  irritated,  the  disease  is  probably  in  the  first  temjioral  convolu- 
tion. If  the  patient  can  understand  and  can  talk,  ]mt  replaces  a  word 
desired  by  one  that  is  unexpected,  the  disease  is  probably  situated  deep 
within  the  Sylvian  fissure,  or  in  the  white  substance  of  the  brain,  and 
involves  the  association  hbers  which  join  the  convolutions  just  named. 

"  In  making  a  diagnosis  of  cortical  disease  care  must  be  taken  to  dis- 
tingiiish  between  direct  and  indirect  local  symi)toms  ;  and  also  to  sepa- 
rate clearly  lesions  of  the  cortex  from  those  of  the  various  white  tracts 
within  the  substance  of  the  brain.'' 

As  far  as  the  disturbances  of  motion  are  concerned,  these  points  of 
interest  bear  such  close  relation  to  the  fissure  of  Rolando  that  it  is  neces- 
sary to  determine  approximately  its  location.     Championniere's  line  is  as 


REGIONAL  SURGERY.— THE  HEAD. 


381 


follows :  From  the  posterior  border  of  the  malar  process  of  the  frontal 
bone,  at  the  upper  outer  angle  of  the  orbit  A  (Fig.  415)  draw  a  line  A  B, 
directly  backward,  a  distance  of  two  and  four  lifths  inches.  From  B 
draw  a  perpendicular  line,  one  inch  and  one  fifth  long,  to  C,  then  from  C, 
upward  and  backward,  to  Z>,  which  shall  tei-minate  in  the  sagittal  suture, 
two  and  one  fifth  inches  directly'  behind  the  junction  of  the  coronal  and 
sagittal  sutures,  B.  The  point  of  junction  of  the  sagittal  and  coronal 
sutures  is  not  always  easily  recognized  in  the  adult.  If,  however,  the 
distance  from  the  root  of  the  nose  (the  naso-frontal  suture)  to  the  poste- 
rior-inferior border  of  the  occipital  protuberance  be  measured,  the  point 
D  (Fig.  415)  wiU  be  found  to  vary  from  three  quarters  of  an  inch  to  an 


Fig.  415.— (Modified  after  Championniere.) 


inch  po.fterior  to  the  center  of  this  line.  The  junction  of  the  sagittal  and 
coronal  sutures  is  directly  above  the  external  opening  of  the  auditory 
canal.  The  researches  of  Championniere  may  practically  be  applied  as 
follows  :  In  complete  and  persistent  hemiplegia,  where  the  history  of  the 
case  may  exclude  extravasation  in  the  deeper  ganglia,  the  center  or  bit 
of  a  large-sized  ti-ephine  should  be  placed  in  the  middle  of  this  line,  at  2 
(Fig.  415),  on  the  side  opposite  to  the  jiaralysis.  If  there  is  loss  of  mo- 
tion or  convulsive  movements  of  the  lower  extremity  alone,  the  trephine 
should  be  applied  in  the  upper  third  of  the  line,  at  3.  When  the  upper 
extremity  alone  is  involved  (the  lesion  being  probably  in  the  middle  third 
of  the  ascending  frontal  convolution),  the  operation  should  be  performed 
opposite  to  the  middle  and  in  front  of  this  line.  When  simple  aphasia 
is  present,  the  trephine  is  to  be  applied  at  the  lower  end.  and  well  in  front 
of  this  line,  1.  If,  when  the  button  of  bone  is  removed,  the  cause  of  the 
compression  is  not  revealed,  the  opening  should  be  enlarged  by  the  ron- 
geur, or  by  reapplying  the  trephine.  The  after-treatment  is  the  same  as 
given  in  trej^jhining  for  injuries  of  the  skull. 


382  A  TEXT-BOOK   ON   SURGERY. 


Surgery  of  TirE  Face. 


Wounds. — Incised-  wounds  of  the  face  usually  blood  profusely.  The 
two  esseutial  features  in  treatment  are  to  arrest  hsoniorrhage  and  secure 
repair  with  the  least  possible  deformity.  When  the  l)l<'edinn:  is  only 
slight,  bringing  the  edges  together  with  line  silk  sutures  will  arrest 
it.  When  ligatures  are  applied,  catgut  should  invariably  be  employed. 
Every  wound  of  the  face  should  be  treated  with  the  strictest  antisepsis. 
The  approximation  of  the  edges  should  be  accomplished  with  exactness. 
The  finest  black  ii'on-dyed  silk  is  the  best  material,  and  the  interrupted 
suture  should  be  preferred.  If  the  character  of  the  luemorrhage  necessi- 
tates central  deligation,  the  external  carotid  (not  the  common  trunk) 
should  be  tied.  This  necessity  could  scarcely  arise  in  an  incised  wound, 
unless  the  internal  maxillary  or  npper  part  of  the  external  carotid  was 
involved. 

Contusions  of  this  region  require,  as  in  other  parts  of  the  liody,  local 
applications,  usually  of  cold  water  or  the  ice-bag.  Ecchymosis  is,  as  a 
rule,  present,  and  is  i)ersistent  in  the  tissues  about  the  eyes. 

Lacerated  wounds  of  the  face  are  serious,  on  account  of  the  danger 
of  disfigurement  after  repair.  If  the  procedure  does  not  involve  much 
loss  of  tissue,  the  edges  may  be  pared  smoothly  and  united  \\ith  silk 
sutures,  under  careful  antisepsis.  If  there  has  been  extensive  contusion, 
a  small  catgut-twist  drain  should  be  left  at  each  end,  to  guard  against 
the  danger  of  infiltration  of  pus  in  the  subcutaneous  tissue.  In  wounds 
which  involve  the  circular  muscles  of  the  eyes  and  mouth,  great  care 
must  be  taken  to  guard  against  contractions  and  deformities. 

Punctured  wounds  require  no  sjiecial  consideration.  Deligation  of 
the  external  carotid  may  be  necessitated  to  arrest  bleeding  from  deep 
wounds  of  the  spheno-maxillary  fossa. 

Shot  wounds  of  the  face  are  not,  as  a  rule,  dangerous  to  life,  even  in 
military  practice.  Of  3,312  cases,  in  which  fracture  of  the  bones  of  the 
face  occurred  as  a  result  of  shot  wounds,  as  given  in  the  "  Medical  and 
Surgical  History  of  the  Civil  War,"  by  Dr.  George  A.  Otis,  only  340  died, 
wdiile  of  4,914  llesli  wounds  only  58  died.  In  civil  practice  the  rate  of 
mortality  is  still  lower. 

When  the  missile  has  penetrated  the  siiheno-maxillary  fossa,  or  di- 
vided any  deei:)-seated  vessels,  the  necessity  of  tying  the  external  carotid 
may  arise.  A  ball  or  any  foreign  body  lodged  in  the  bones  or  tissues  of 
the  face  should  be  immediately  removed,  when  this  can  be  accomplished 
without  an  operation  which  may  incur  the  danger  of  deformity.  When, 
however,  the  missile  is  deeply  lodged,  and  is  of  small  size,  it  should  not 
be  molested  until  there  is  evidence  that  it  will  not  remain  encapsuled 
and  harmless. 

Bones  or  fragments  of  bone  which  have  been  displaced  in  part,  but 
not  entirely  stripped  of  periosteum  and  vascular  attachments,  must  not 
be  removed,  since,  if  replaced  and  held  in  proper  position,  they  usually 
become  reunited  to  the  sound  bone. 


DISEASES  OF  THE  EYELIDS. 


383 


Surgery  and  Surgical  Diseases  of  the  Eyelids  and  of  the  Or- 
bital Cavity  (xot  including  Lesions  of  the  Globe). 

Wounds  of  the  eyelids  and  of  the  circular  muscle  of  the  eye  scarcely 
require  special  consideration.  In  incised  or  lacerated  wounds  a  careful 
approximation  of  the  edges  of  such  wounds  with  the  finest  silk  sutures, 
and  the  maintenance  of  the  parts  in  a  condition  of  perfect  quiet,  are 
essential.  The  sublimate  and  carbolic-acid  solutions  can  not  be  emi)loyed 
when  the  surface  of  the  eye  is  exposed.  A  saturated  solution  (about  grs. 
XV  -  5  j  of  water)  of  boracic  acid  is  to  be  preferred  for  purposes  of  clean- 
liness. Contusions  about  the  eye  should  be  treated  by  cold  applications, 
using  a  very  small  and  light  ice-bag,  or  frequent  changes  of  bits  of  linen 
cloth,  taken  from  a  block  of  ice. 

NeiD  Formations. —  Vascular  groictTis  (njevi  or  angeiomata),  usually 
of  the  capillary  variety,  are  not  infrequent  in  the  vicinity  of  the  eye. 
When  of  small  size,  not  exceeding  a  half  or  three  fourths  of  an  inch,  they 
may  be  successfully  destroyed  by  the  hypodermic  injection  of  from  two 
to  five  minims  of  a  50-per-cent  solution  of  carbolic  acid.  Great  care 
should  be  taken  not  to  allow  any  of  the  solution  to  enter  the  eye. 

Removal  by  free  excision  is  not  practicable  when  the  tumor  is  of  large 
size,  and  when  the  palpebral  margins  are  involved,  or  when  their  shape 
and  situation  are  such  that  deformity  is  apt  to  follow  the  excision.  A 
careful  application  of  the  rules  of  plastic  surgery  to  the  region  of  the  eye 
will  often  oljviate  deformity,  even  after  extensive  dissections  with  loss  of 
tissue  in  the  vicinity  of  this  organ.  What  has  been  said  of  the  excision 
of  vascular  growths  applies  equally  to  all  fomis  of  neoplasms  in  this 
region  which — themselves  a  deformity,  or  malignant  in  character — require 
removal. 

When  the  lower  lid  is  encroached  upon,  it  is  of  the  utmost  importance 
that  the  palpebral  margin  be  left  intact  for  at  least  one  eighth  of  an  inch, 


Fig.  416. 


Fig.  417. 


and  as  much  more  as  is  consistent  ^^-jth  the  free  excision  of  the  tumor. 
One  incision  .should  be  parallel  with  the  border.  The  palpebral  branch 
of  the  ophthalmic  artery,  which  runs  j)arallel  with  and  about  this  dis- 


384 


A   TEXT  HOOK   ON   SUKGKRY. 


tance  fmiii  I  In-  I'lvc  iimruin  of  tlip  lid,  f^lioiikl  not  be  wounded  when  it  is 
possible  to  avoid  it.     When  tlie  dissection  is  completed,  a  tonp:ue  of  skin 

may  be  slid  from  the  malar  re- 
gion across  the  wound.     Fig. 

416  represents  the  space  left 
after  the  removal  of  a  myxo- 
sarcoma of  the  face,  and  Fig. 

417  the  method  of  covering  in 
the  deJiciency.  From  the  outer 
angles  jiarallel  incisions  were 
continued  through  the  skin 
toward  the  ear,  as  far  as  was 
necessary  to  secure  integument 
enough  to  slide  across  the  gap. 
The  transverse  facial  artery, 
which  runs  about  one  fourth 
of  an  inch  below  and  i)arallel 
with  the  zygoma,  should  be 
kept  in  the  flap,  which  is  dis- 
sected up  until  the  end  near- 
est the  nose  can  be  carried 
across  to  the  edge  of  the  wound 
upon  the  nose  and  stitched  at 
this  point.  The  lower  border 
is  next  fastened,  and  after  this 

the  palpebi-al  border  is  stitched  to  the  upper  margin  of  the  tongue  of 
skin  with  the  finest  suture  ma- 
terial. The  sutures  may  be  re- 
moved in  from  two  to  four 
days.  It  is  necessary  to  aiTest 
all  bleeding  from  the  bottom 
of  the  cavity  left  after  a  dissec- 
tion ;  that  from  the  edges  wall 
be  arrested  by  the  sutures. 
The  tension  on  the  flap  should 
not  be  so  great  that  the  blood- 
supply  is  seriously  interfered 
with.  After  the  first  sutures 
are  inserted  it  will  be  well  to 
wait  for  a  few  minutes  in  order 
to  see  that  the  circulation  is 
established.  Figs.  418  and  419 
are  taken  from  a  patient  from 
whom  a  large  na?vus  was  ex- 
cised, and  the  wound  iilled  by 
free  dissection  and  sliding  of 
the  integument  of  the  cheek. 
Little  or  no  eversion  or  drag- 


Fio.  418. 


Fig.  419. 


DISEASES  OF  THE  EYELIDS.  385 

ging  down  of  tlie  lid  will  follow  in  these  operations  when  carefully  j-jpr- 
formed. 

Sebaceous  tumors  (retention-cysts)  are  occasionally  met  with  on  tlie 
outer  surface  of  the  lids,  and  in  the  skin  about  the  orl)it.  They  should 
be  removed  by  thorough  dissection  of  the  sac.  When  situated  upon  the 
lids  they  rest  between  the  integument  and  the  tarsal  cartilage.  The  line 
of  incision  should  be  parallel  with  the  free  border  of  the  lid,  to  avoid 
dividing  the  horizontal  fibers  of  the  orbicularis  muscle. 

A  more  frequent  swelling  of  the  edge  of  the  lid,  commonly  known  as 
a  stye  {hordeolitm),  results  from  an  inflammation  of  the  sebaceous  and 
hair  follicles  at  the  palpebral  margin.  It  is  a  furuncle  of  the  lid.  The 
treatment  consists  in  early  evacuation  of  the  contents  of  the  Ixtil  by 
pricking  with  a  needle  or  lancet.  Warm  or  emollient  applications 
hasten  the  suppurative  process  and  soften  the  covering  of  epidermis. 

Obstruction  of  one  or  more  of  the  ducts  of  the  MeiboTnian  glands 
causes  a  swelling  and  inflammation  of  the  gland,  or  tube  beliind  the  point 
of  obstruction.  These  protrusions  appear  on  the  conjunctival  surface  of 
the  tarsal  cartilage,  and  should  be  treated  by  puncttire,  with  evacuation 
of  their  contents  by  pressure ;  or  by  pressure  on  both  surfaces  of  the  lid, 
directed  from  the  base  toward  the  free  border,  in  the  effort  to  squeeze 
out  the  plug  and  thus  restore  the  normal  condition  of  the  excretory  duct. 
Any  incision  on  the  under  surface  of  the  lids  should  be  nuide  parallel 
with  the  ducts  of  these  glands.  A  rare  form  of  cystic  tumor,  known  as 
chalazion,  occasionally  develops  in  the  substance  of  the  tarsal  cartilage. 
It  may  be  cured  by  incision  and  destruction  of  the  sac,  or  by  evacuating 
the  contents  and  injecting  one  minim  of  50-iDer-cent  carbolic  acid  into 
the  cyst. 

Blepharitis  or  inflammation  of  the  lids  may  affect  all  or  a  limited 
portion  of  these  organs.  It  most  frequently  involves  the  ciliary  margins, 
and  is  known  as  blepharitis  ciliaris.  In  rare  instances  the  cartilages  are 
involved.  Acute  blepJiaritis  demands  rest  and  local  antiphlogistic  appli- 
cations. Cloths  dipped  in  warm  water  are  in  general  more  agreeable. 
In  chronic  blepharitis  ciliaris  the  scaly  covering  of  the  inflamed  borders 
of  the  lids  should  be  removed  by  the  prolonged  use  of  warm  boracic-acid 
water  and  a  mop  of  soft  lint,  having  first  trimmed  the  lashes  closely. 
When  this  is  dcme  the  inflamed  surface  should  be  lightly  touched  with  a 
pencil  of  lunar  caustic.  At  night  the  lids  should  be  lubricated  with  a 
small  quantity  of  cosmoline. 

Conjunctivitis  or  inflammation  of  the  ocular  and  palpebral  conjunc- 
tiva may  be  acute  or  chronic  in  character.  The  causes  are  traumatic, 
idiopathic,  and  contagious.  A  severe  form  of  this  disease,  in  which 
the  formation  of  pus  is  abundant,  is  known  as  p^irulent  conjuncti- 
vitis. Another  form,  known  as  phlyctenular  conjunctivitis,  is  charac- 
terized by  the  apx^earance  of  one  or  several  centers  of  inflammation, 
each  spot  being  somewhat  elevated  above  the  general  surface.  This 
variety  is  almost  always  met  with  in  children  suffering  from  an  inherited 
dyscrasia. 

Among  the  more  common  forms  of  contagious  conjunctivitis  are  those 

-      25 


386  A  TEXT-BOOK  OX  SURGERY. 

met  with  in  the  newly  born  {oplithalmia  neonatorum) :  gonorrhoeal  and 
diph  fheritic  ophthalmia . 

Trrdfiitrnf. — Acute  simjile  ronjunctivitis,  whetlipr  trainiiati("  or  idio- 
pathic, should  be  tr^-ated  by  iH-rrecl  rest  to  the  parts  involved.  When 
a  foreign  body  is  lodged  upon  the  cornea,  sclerotic,  or  conjunctiva,  its 
removal  is  essential.  The  employment  of  cocaine  (2-4-per-cent  solu- 
tion) renders  the  operation  painless,  and  is  useful  in  other  forms  of 
conjunctivitis.  Recovery  is  always  much  more  rapid  if  the  patient 
is  confined  in  a  dark  or  dimly  lighted  apartment.  Bits  of  borated  cot- 
ton or  lint,  wet  in  cold  water,  or  taken  from  a  block  of  ice,  and  laid 
over  the  organ,  will  hasten  recovery.  If  pus  should  be  present  and 
collect  in  the  angles  of  the  lids,  it  should  l)e  mopped  out  with  pellets 
of  borated  cotton  moistened  in  boracic-acid  solution,  grs.  x-xv  to  §  j  of 
water. 

Chronic  conjnnct'nHtis  (granular  lids  or  trachoma)  may  follow  any 
form  of  acute  inflammation  of  this  membrane.  The  pathohxj;/  of  this 
condition,  from  whatever  cause  it  may  result,  is  practically  the  same. 
The  conjunctiva  is  injected  with  newly  formed  capillary  loops  and  thick- 
ened by  the  formation  of  an  embryonic  tissue,  the  result  of  cell-prolifera- 
tion. This  granulation-tissue  may  be  confined  to  the  mucous  membrane 
alone,  or  it  may  involve  the  submucous  tissue,  the  cartilages,  cornea, 
and  sclerotic.  Ulceration  occurs  in  a  certain  proportion  of  cases ;  in 
others  cicatricial  contractions  take  place,  leading  to  distortions  of  the 
lids,  or  adhesions  between  the  lids  and  globe. 

The  treatment  is  local  and  general.  The  local  treatment  looks  to  the 
absorption  of  the  products  of  the  inflammatory  process ;  the  general 
treatment,  to  the  improvement  of  the  patient's  nutrition.  The  application 
of  solid  sulphate  of  copper  is  a  remedy  of  unequaled  excellence.  It 
is  far  preferable  to  nitrate  of  silver  on  account  of  the  danger  of  the 
latter  of  staining  the  cornea  when  the  excess  is  not  immediately  washed 
off.  Before  using  the  blue-stone  the  eye  should  be  deprived  of  its  sensi- 
bility by  dropping  two  or  three  minims  of  4-per-cent  cocaine  into  the 
organ  at  intervals  of  five  minutes  for  from  twenty  to  thirty  minutes. 
The  upper  lid  should  be  everted  by  directing  the  patient  to  look  down, 
while  the  operator  with  the  thumb  and  index-finger  seizes  the  lid  with 
the  ciliae  at  its  margin,  and  depresses  it  further.  The  upper  margin  of 
the  cartilage  should  now  be  fixed  by  the  tip  of  one  of  the  fingers  of  the 
other  hand,  while  the  lid  is  suddenly  turned  up.  Or,  when  the  lid  is 
depressed,  lay  a  probe  parallel  with  the  upper  margin  of  the  cartilage, 
and  evert  the  lid  over  this.  The  copper  pencil  may  now  be  swept  over 
the  granulations.  The  extent  to  which  the  caustic  is  used  will  depend 
upon  the  condition  of  the  organ.  If  the  granulations  are  not  exuberant, 
it  may  be  lightly  swept  over  the  surface,  and  the  excess  washed  off  by 
boracic-acid  solution.  If  the  injection  is  deep  and  the  vascularity  great, 
the  i)oint  may  be  more  slowly  carried  over  the  membrane,  and  the  wash- 
ing omitted.  The  cocaine  should,  however,  be  continued,  in  order  to 
prevent  the  severe  pain  which  otherwise  follows  the  application.  As  a 
rule,  it  is  better  to  use  the  milder  treatment  at  frequent  intervals  rather 


DISEASES   OF  THE  EYELIDS. 


387 


than  run  the  risk  of  indncing  too  great  reaction  by  deeper  cauterization. 
In  the  successful  employment  of  this  agent  it  is  essential  that  it  be  car- 
ried into  all  the  folds  and  pockets  of  the  thickened  conjunctiva.  Suet, 
oil,  or  cosmoline  shoukl  be  rubbed  on  the  edges  of  the  lids  to  prevent 
adhesions.  In  severe  cases  of  trachoma,  which  resist  all  conservative 
measures,  three  radical  methods  are  recommended.  The  first  of  the.se  is 
scarification  of  the  lids,  and  is  applicable  when  the  granulations  are  con- 
fined chiefly  to  the  palpebral  conjunctiva.  Anaesthesia  should  be  induced 
by  cocaine,  as  heretofore,  the  lids  everred,  and  from  two  to  eight  lines 
of  scarification  through  the  granulations  made  by  the  lancet  carried 
parallel  with  the  free  border  of  the  lid.  The  division  of  the  vessels  and 
the  cicatrization  which  ensues  cause  a  diminution  of  the  blood-supply, 
and  absorption  of  the  products  of  inflammation. 

When  the  ocular  conjunctiva  is  also  seriously  involved,  a  cure  may 
be  effected  by  the  induction  of  gonorrhopal  ophthalmia.  A  small  quan- 
tity of  the  virus  is  placed  upon  the  conjunctiva,  and  the  resulting  in- 
flammation is  treated,  as  given  hereafter,  for  this  specific  form  of  con- 
junctivitis. 

The  use  of  jequirity-bean  is  at  this  date  very  popular  with  ophthalmic 
surgeons  in  the  treatment  of  jJcinm/s.  Prof.  Webster  advises  its  employ- 
ment in  one  of  the  following  ways  :  One  jeqiairity-bean  coarsely  powdered 
is  placed  in  an  ounce  of  water  for  four  hours.  The  patient  is  then  re- 
quired to  bathe  the  affected  eye  very  freely  with  this  solution  for  ten  or 
fifteen  minutes,  letting  some  of  it  get  into  the  eye.  One  thorough  wash- 
ing will  usually  produce  the  characteristic  membrane  of  the  conjunctiva 
If  this  does  not  succeed,  the  operation  should 
be  repeated.  Or  the  bean,  very  finely  pulver- 
ized, may  be  applied  to  the  whole  palpebral 
conjunctiva. 

It  is  desirable  in  all  forms  of  conjunctivi- 
tis to  shield  the  eye  from  the  light.  A  con- 
venient shade  or  screen  for  this  purpose  is 
shown  in  Fig.  420. 

Conjunctivitis  in  the  new-born  {opJdTial- 
mia  neonatoriijri)  is  a  form  of  purulent  oph- 
thalmia which  usually  results  from  the  inocu- 
lation of  the  conjunctiva  with  septic  matter 
present  in  the  genital  passages  of  the  mother. 
It  may  come  from  carelessness  on  the  part  of 
the  nurse,  herself  affected  with  a  leucorrhoea, 
etc.,  or  from  the  lodgment  of  any  virus  in  the 
eye  of  the  child.      The  treatment  is  propliijlactic  as  well  as  curative. 

The  eyes  of  a  child  bom  of  a  mother  known  to  be  suffering  from  a 
vaginal  discharge  of  a  purulent  character  should,  as  soon  as  possible 
after  birth,  be  washed  or  mopped  out  with  clean  warm  water,  or  boracic- 
acid  solution,  to  be  followed  with  one  or  two  drops  of  a  2-per-cent  ni- 
trate-of-silver  solution  (grs.  ijss.-§j)  once  or  twice  a  day,  for  three  or 
four  days. 


Fig.  -120. 


388  A  TEXT-BOOK   ON   SURGERY. 

Wlipn  the  disease  is  declared,  tlic  i»us  slumld  be  gently  removed 
from  the  eye  by  pellets  of  soft  lint  or  absorbent  cotton,  dipped  in  warm 
boracic-acid  solution,  the  lids  everted,  and  nitrate-of-silver  solution  (grs. 
v-x  to  3J)  ai:)plied  to  tlie  inllamed  surfaces  by  means  of  a  camel's-liair 
brusli.  The  excess  should  be  immediately  washed  away  by  the  free  use 
of  warm  water.  This  shoidd  be  re])eated  every  day  until  the  ])urulent 
discliarge  is  notably  diminislied.  Boracic  acid  water  (grs.  v-5  j)  should 
be  used  several  times  each  day  after  the  application  of  the  nitrate  of 
silver. 

Gonorrliaal  Op/t///n////i<i. —CoujnnL-tiyitis  caused  by  the  introduction 
of  the  virus  of  gonorrhoea  into  the  eye  should  be  treated  with  great  care 
and  persistency  fnmi  the  first  symi>toiu  of  this  painful  affection.  I'sually 
a  single  organ  is  attacked.  It  is  ini])ortant  that,  while  the  eifort  to  cure 
one  is  being  made,  the  other  should  be  protected  from  the  contagion. 
To  effect  this,  a  watch-glass,  to  the  edge  of  which  adhesive  plaster  is  at- 
tached, is  placed  over  the  sound  eye  and  closely  fastened  to  the  skin 
about  the  orbit  by  the  plaster,  so  that  it  is  hermetically  sealed.  This 
should  not  be  removed  until  the  other  eye  is  well. 

In  the  local  treatment  of  the  affected  eye  it  is  required  to  remove  the 
purulent  discharge  by  frequent  irrigation  with  waiTQ  boracic-acid  water 
or  by  the  pellets  of  lint  or  absorbent  cotton,  and  to  brush  over  the  everted 
lids  once  or  twice  a  day,  as  the  attack  is  light  or  severe,  a  solution  of 
nitrate  of  silver  (grs.  xx  to  3J).  The  excess  slumld  be  immediately 
washed  off  with  tepid  water.  Cold  applications  are  of  great  importance, 
and  a  very  efficient  method  is  to  apjily  frequent  changes  (every  one  or 
two  minutes)  of  pieces  of  lint  about  two  inches  square,  which  are  taken 
directly  from  a  block  of  ice  and  laid  over  the  inflamed  organ.  In  this 
form  of  conjunctival  inflammation,  as  in  others  where  the  injection  is 
mai-ked  and  the  thickening  great,  and  where  painful  bh'jjJta/u-ym.s-m 
occurs,  or  where  a  free  discharge  of  purulent  matter  can  not  be  elfected 
by  ordinary  means,  canfJiopJaMi/  is  required.  Tliis  operation  consists 
in  slitting  the  outer  canthus  in  the  direction  of  the  ear,  and  in  this  way 
dividing  the  fibers  of  the  orbicular  muscle. 

In  gonorrhceal  conjunctivitis  the  impairment  of  function  in  the  mus- 
cle is  not  intended  to  be  of  long  duration,  and  the  wound  is  left  open. 
In  some  cases  of  spasm  of  this  muscle,  and  where  a  chronic  inflammation 
exists,  the  mucous  membrane  is  stitched  to  the  skin  along  the  edges 
of  the  wound,  thus  preventing  a  reunitm.  Reunion  may  be  effected 
later  by  paring  the  edges  and  bringing  the  parts  together  after  the 
lesion  for  which  the  canthoplasty  was  performed  is  healed.  Cocaine 
should  be  used  to  relieve  pain,  and  all  adhesion  between  the  ocxdar  and 
paljiebral  mucous  surfaces  .should  be  liroken  up  as  soon  as  discovered. 

DipMlieritic  conjunctivitis  is  a  rare  form  of  disease  in  which  the 
diphtheritic  membrane  is  formed  upon  the  conjunctiva.  It  should  be 
treated  by  cold,  apjilied  as  in  gonorrha'al  conjunctivitis.  The  eyes 
should  be  cleansed  with  warm  boracic-acid  solution,  as  heretofore  de- 
scribed, and  nitrate-of-silver  solution  applied  once  a  day,  in  the  strength 
of  grs.  v-x  to  5j. 


DISEASES  OF  THE  EYELIDS. 


389 


Phlyctenular  conjunctivitis,  as  has  been  stated,  is  almost  always  an 
expression  of  a  constitutional  disease,  as  syphilis,  tuberculosis,  etc.,  and 
requires,  in  addition  to  local  measures,  a  course  of  treatment  for  tlie 
palliation  or  cure  of  the  dyscrasia  which  prevails.  The  local  treatment 
of  the  pMyctenul(B  is  to  dust  the  inflamed  spots  once  a  day  with  calo- 
mel, or  to  introduce  Isetween  tlie  lids  a  small  quantity  of  calomel  oint- 
ment (grs.  j-ij  to  Z  j  of  cosmoline).  Astrinneuts,  as  already  described  in 
chronic  conjunctivitis,  should  also  be  employed  to  cause  absorption  of 
the  products  of  inflammation. 

Symhli'pJiaron,  or  adhesion  of  the  lids  to  the  globe  of  the  eye,  may  fol- 
low any  form  of  conjunctivitis.  The  treatment  in  mild  and  recent  cases 
consists  in  repeatedly  breaking  up  the  adhesions  until  the  epithelium 
of  the  conjunctiva  is  develojDed  over  the  raw  surfaces,  or  the  edges  of 
the  wound  left  by  the  dissection  may  be  brought  together  by  sutures. 
In  severe  cases,  after  the  adhesions  are  dissected  loose,  a  cure  may  be 
efi'ected  by  making  a  plastic  operation,  which  consists  in  sliding  the 
contiguous  healthy  mucous  membrane  across  the  raw  surface  and  se- 
curing it  by  fine  silk  sutures. 

Ectropion,  or  eversion  of  the  lid,  usually  follows  chronic  conjuncti- 
vitis and  blepharitis,  or  is  caused  by 
cicatricial  contractions  after  injuries 
located  in  the  tissues  near  the  eye. 
The  treatment  is  chiefly  operative, 
and  consists  in  the  relief  of  the  ten- 
sion which  is  causing  the  displace- 
ment. When  cicatricial  contractions 
have  produced  the  deformity,  a  par- 
tial or  complete  restoration  of  the 
function  and  position  of  the  lid  may 
be  obtained  by  a  careful  and  thor- 
ough dissection  of  the  cicatrix,  and 
immediately  filling  in  the  wound  by 
transplantation  of  skin. 

The  integument  about  the  eye  is 
remarkably  tolerant  in  plastic  opera- 
tions, and,  with  care  and  skill,  relief 
will  follow  in  almost  eveiy  instance. 
The  operation  known  as  sliding  was 
done  in  the  case  of  the  patient  from 
whom  Fig.  421  was  taken,  as  repre- 
senting a  typical  traumatic  ectro- 
pion. The  eversion  was  caused  by 
an  injury  to  the  integument  of  the 
naso-maxillary  region,  with  fracture 
of  the  nasal  process  of  the  superior 
maxilla.  The  first  opei-ation  consist- 
ed in  a  removal  of  the  cicatrix  from  near  the  inner  canthus  and  side  of 
the  nose.     Two  incisions  were  then  made — one  parallel  with  and  about 


#^ 


Fig.  421. — Ectropion  due  to  cicatricial  contrac- 
tions tbUowiiig  a  wound  of  the  naso-mu.\illary 
rciiion. 


390 


A  TEXT-BOOK  ON  SURGERY. 


one  fourth  of  an  inch  I'lnm  the  edge  of  the  everted  lid,  and  ;i  second  aboiit 
three  quarters  of  an  inch  below  this — out  as  far  as  the  malar  protuberance. 
This  rectanijular  Hap  was  dissected  up  and  stretched  across  the  gap 
already  made,  and  stitched  in  position,  as  in  Fig.  417.  As  this  was  done 
the  lid  was  lifted  high  enough  to  permit  the  complete  closure  of  the  eye. 
Tiie  second  operation  consisted  in  the  removal  of  a  long  elliptical  strip 
from  the  thickened  granulation-tissue  which  covered  the  evertetl  conjunc- 
tiva. This  was  done  by  picking  it  up  with  fine  mouse-tooth  forceps  and 
clipping  the  mass  thus  seized  with  the  curved  scissors.  The  long  axis  of 
this  wound  was  parallel  with  the  edge  of  the  lid,  and  extended  from  the 
punctum  lachrymale  almost  to  the  outer  canthus.  The  edges  of  the  con- 
junctiva were  stitched  with  fine  silk  sutures.  It  is  of  great  inii)()rtance 
that  too  great  tension  be  not  made  upon  the  flap.  If,  after  it  is  stitched 
across  the  gap  to  be  covered,  the  circulation  is  interfered  with,  the  ten- 
sicm  should  be  relieved,  and  that  jiart  of  the  wound  left  open  should  be 
filled  by  grafting  or  transplantation  en  masse.  Eversicm  of  the  lid,  with 
great  thickening  of  the  cartilage  and  conjunctiva  from  chronic  blej^ha- 
ritis,  may  be  in  part  corrected  by  the  excision  of  an  elliptical  piece  re- 
moved in  the  long  axis  of  the  lid.  The  section  should  include  a  portion 
of  the  cartilage,  and  the  wound  closed  by  bringing  the  edges  of  the  con- 
junctiva together  with  fine  silk  sutiires. 

Another  procedure  is  to  remove  a  kite-shaped  segment,  including  all 
the  tissues  of  the  lid  and  skin  near  the  orbit,  as  shown  in  Fig.  422,  and 
then  bringing  the  edges  of  the  wound  together  by  pin  or  silk  sutures, 
as  shown  in  Fig.  423.     The  section  is  made  near  the  outer  canthus. 


Fio.  422.— (After  Gross.) 


Fig.  423.— (After  Gross.) 


Entropion,  or  incurvation  of  the  lids,  may  be  relieved  by  removing 
an  elliptical  piece  of  the  integument  covering  the  lid.  The  width  of  the 
section  must  be  determined  by  the  degree  of  inversion.  When  there  is 
shortening  of  the  lid  in  its  long  axis,  much  relief  will  be  afforded  by 
canthoplasty .  In  extreme  cases,  where  the  cartilage  is  greatly  thickened, 
the  section  should  include  a  strip  of  this  substance. 

Ptosis,  or  inability  to  raise  the  upper  eyelid,  is  due  to  paralysis  of 
the  levator  palpehrce  muscle.  The  medical  treatment  looks  to  the  im- 
provement of  the  tone  of  this  muscle,  or  to  the  cure  of  the  central  lesion 


DISEASES   OF  THE   EYELIDS. 


391 


whicli  may  cause  it.  The  surgical  treatment  consists  in  the  excision  of 
an  elliptical  piece  from  the  skin  of  the  upper  Ud  and  the  approximation 
(jf  the  edges  by  sutures. 

Trichiasis,  or  turning  in  of  the  eyelashes,  occurs  with  entropion,  but 
may  exist  independently.  Occuning  with  inversion  of  the  lid,  it  does 
not  require  any  other  interference  than  that  given  for  the  cure  of  entro- 
pion. When  the  cilise  turn  in  without  inversion  of  the  lid,  the  proper 
method  of  treatment  is  total 
excision  of  the  hair-follicles. 
This  should  be  accomplished 
by  two  parallel  incisions  made 
along  the  margin  of  the  lid, 
one  on  either  side  of  the  row 

of  hairs,  and  extending  deep  enough  to  insure  the  complete  removal  of 
the  roots  of  the  cilife.  When  depilation  is  demanded,  the  instrument 
shown  in  Fig.  424  will  be  found  of  great  service. 

Epiphora,  or  overflow  of  the  lachrymal  secretion,  may  be  due  to 
paralysis  of  the  orbicularis  palpebrarum,  or  to  any  condition  which 
causes  displacement  or  obstruction  of  the  lachrymo-nasal  duct.  In  mild 
epiphora  due  to  displacement  of  the  inferior  punctuin  lachrymale  the 
treatment  consists  in  the  dilatation  of  the  canaliculus  by  the  repeated 
introduction  of  a  conical  probe,  followed  by  incision.     This  latter  oper- 


Fia.  424. — Gruening's  depilating-forceps. 


^n**  W  H""-*!*!"!"*) 


Fig.  425. — Jsoves's  movable  blade  canaliculus-knifo. 


C  TrEWAfWaCO 


Fig.  426. —  Weber's  curved  canaliculus-knife. 


ation  is  done  by  inserting  the  probe-pointed  knife  or  scissors  (Figs.  425, 
426,  427),  made  for  this  purpose,  into  the  punctum  and  along  the  canal 
for  about  one  sixth  of  an  inch,  and  slitting  the  canaliculus  to  this  extent. 
The  w^ound  should  be  kept  open  by  forcibly  separating  its  edges  once  or 
twice  a  day,  ^^ntil  the 
cut  surfaces  are  covered 
with  epithelium,  and  the 
trough  remains  open. 

Obstruction  of  the 
lachrymonasal  duct  may 
in  some  cases  be  over- 
come by  dilatation.  In 
acute  or  chronic  dacnjo- 
cystitis  it  is  the  common 
practice  to  slit  open  the 
upper  canaliculus ;  in  case  of  abscess,  to  give  free  discharge  to  the  inflam- 
matory products,  and,  if  stricture  is  threatened,  to  permit  the  introduc- 


Fio.  427. — Maunoir's  eanaUculus-scissors. 


392 


A  TEXT-BOOK  ON  SURGERY. 


tion  of  dilating-sounds.  The  upper  piinctum  should  l)e  dilated  in  the 
same  manner  as  given  for  tlie  lower,  a  i)ro))e-p()iiited  knife  or  scissors 
introduced,  and  the  canal  slit  ■well  into  the  lachryino-nasal  sac.  The 
bulb-pointed  dilating-probes  should  now  be  carefully  introduced,  be- 
ginning witli  the  smaller  sizes  (Fig.  42.8).     As  soon  as  the  bulb  enters 


Fio.  428. — Williams's  set  of  hichrymal  probes,    a,  b,  Probes,     c,  Dilator,     n,  e,  Styles. 

the  sac  it  should  be  gently  and  slowly  directed  along  the  nasal  duct  until 
it  is  arrested  by  the  floor  of  the  nose.  The  larger  sizes  may  be  intro- 
duced as  in  the  treatment  of  stricture  of  the  urethra.  After  full  dila- 
tation is  secured  the  channel  should  be  washed  out  daily,  for  about 
ten  days,  with  a  1-per-cent  boracic-acid  solution.  For  this  purpose 
Anel's  syringe  (Fig.  429)  will  be  found  useful.     The  probe-pointed  nozzle 


Fig.  429. — .Unci's  silver  eye-syringe,  silver  and  gold  points. 

is  introduced  into  the  sac  and  the  water  forced  through  until  it  flows 
freely  into  the  nose.  If  the  obstruction  recurs,  the  probes  should  be  re- 
introduced. 

Tlie  Orbital  Capify. — Wounds,  absces.ses,  and  tumors  of  the  orbital 
cavity  demand  no  especial  consideration.  The  same  rules  of  practice 
prevail  here  as  elsewhere.  Benign  neoplasms  do  not,  as  a  rule,  involve 
the  eye  in  their  removal.  Malignant  growths  usually  demand  a  tlior- 
ough  extirpation  of  all  the  contents  of  this  cavity.  Vascrilar  tuitiors 
of  the  orbit,  so-called  infra-orbital  aneurisms,  not  infrequently  require 
deligation  of  the  common  carotid  artery,  and  in  some  instances  extir- 
pation of  the  mass  from  the  orbital  cavity.  The  indication  for  the  first 
operation  is  marked  arrest  or  diminution  of  the  pulsation  and  size  of  the 
tumor  after  compression  of  the  carotid  in  the  neck.  (See  chapter  on  the 
Arteries.) 


SURGERY  OF  THE  EAR. 


893 


Surgery  of  the  Ear. 

Neoplasms  of  the  auricle  require  extirpation  as  in  other  portions  of 
the  body.  Angeiomata  of  small  size  may  be  cured,  without  excision,  by 
injecting  the  tumor  with  a  few  minims  of  50-per-cent  carbolic-acid  solu- 
tion. Cart  Hag  Inous  growths  are  occasionally  met  with  about  the  ear. 
Their  usual  location  is  just  in  front  of  the  tragus.  I  removed  two  in 
front  of  one  ear  and  one  from  the  opposite  side  in  a  patient  twenty-two 
years  of  age.  Similar  tumors  were  present  in  the  person  of  his  father 
and  another  member  of  the  family. 

Wounds  of  the  auricle  should  be  treated  with  the  view  of  preventing 
any  distortion  of  this  organ. 

Lacerations  of  the  lobule  from  the  violent  removal  of  an  ear-ring  may 
be  corrected  by  paring  the  edges  and  uniting  them  by  fine  silk  sutures. 
The  hypodermic  use  of  cocaine  will  secure  pei-fect  anaesthesia  in  all  or- 
dinary operations  upon  the  auricle. 

Drooping  of  the  ears  to  a  degree  amounting  to  deformity  should  be 
treated  in  children  by  strapping  the  auricles  close  to  the  skull,  by  means 
of  an  elastic  band  around  the  forehead  and  occiput. 


Fio.  430.— (.\fter  Keeves.) 


Fig.  431.— (After  Beeves.) 


Adhesions  of  the  auricles  to  the  scalp  should  be  dissected  loose,  the 
organs  crowded  forward,  and,  if  necessary,  skin  shoiild  be  transplanted 
to  fill  in  the  gap  and  prevent  a  i-ecun-ence  of  the  deformity.  Hyper- 
trophy of  the  auricle  should  be  corrected  by  excision  of  a  triangular 
piece,  after  the  method  of  Martino,  shown  in  Figs.  430  and  431. 


Fio.  432.— Se.\ton's  hard-rubber  double  probe. 


Auditory  Canal. — Foreign  bodies  in  the  auditory  canal  maybe  recog- 
nized by  inspection  or  with  the  light  gutta-percha  probe  (Fig.  432),  and 
should  be  removed  by  the  careful  employment  of  the  angular  forceps 


394 


A  TEXT-BOOK   ON   SURGERY. 


(Fig.  433),  or,  if  firmly  impacted,  the  ring  curette  (Fig.  434)  may  be  re- 
quired. For  locating  and  seizing  the  body  the  head-mirror  should  be 
employed  to  concentrate  the  light  in  the  canal.     The  solid-silver  specu- 


FiG.  433. — Sexton's  ear-forceps. 


Fig.  434.— Sexton's  double  ear-hook,  to  extract  foreign    bodies. 

him  of  Wilde,  always  required  in  examinations  of  the  deeper  portions  of 
the  canal  and  of  the  membrana  tympani,  may  also  be  of  assistance  in 
locating  the  foreign  body,  although  this  can  usually  be  done,  if  the  light 
is  properly  directed,  by  pulling  ux^on  the  auricle  so  as  to  straighten  the 
canal. 

Impactions  of  cerumen  should  be  removed  by  irrigation  with  warm 
water.  The  stream  should  be  delicate,  and  should  be  directed  to  one 
side  of  the  obstruction  in  order  to  melt  away  a  portion  sufficient  to  allow 
the  force  of  the  injection  to  operate  upon  the  mass  from  behind.  The 
curette  or  scooji  may  also  be  advantageously  employed  in  removing  im- 
pactions of  cerumen. 

Furuncles  of  the  auditory  canal  are  quite  frequently  met  with.  Their 
presence  is  marked  by  acute  pain,  located  in  a  circumscribed  area,  and 
by  redness  and  swelling. 

The  treatment  consists  in  alleviating  pain  by  the  use  of  anodynes  if 
necessary,  and  by  softening  the  skin  over  the  inflammatory  process  by 
the  use  of  emollients.  Cotton  lubricated  with  vaseline  should  be  intro- 
duced. As  soon  as  the  formation  of  pus  is  evident,  it  should  be  evacuated 
by  puncture  or  incision. 


Flo.  435. — Sexton's  snare. 


Neoplasms  of  the  auditory  canal  demand  removal  by  the  snare  (Fig. 
435),  forceps,  or  by  excision.     Polypus  of  this  tube  may  be  single  or 


SURGERY   OF  THE   EAR.  395 

multiple,  and,  when  of  sufficient  size  to  fill  the  canal  and  become  con- 
stricted, may  break  down  and  cause  a  foetid  discharge. 

Occasionally  the  auditory  canal  is  occupied  l)y  a  parasite  known  as 
aspergillas^  the  spores  of  which  are  developed  with  great  rapidity,  fill- 
ing up  the  canal  and  causing  inflammation,  obstruction,  and  more  or  less 
interference  with  hearing.  Finely  powdered  boracic  acid  should  be 
blown  deeply  into  the  canal  at  repeated  intervals  until  the  fungus  is 
destroyed. 

Middle  Ear — Membrana  Ti/mjmni. — The  drum  of  the  ear  may  be- 
come involved  by  extension  of  an  inflammation  from  the  auditory  canal, 
or  it  may  be  secondary  to  an  otitis  media,  or  it  may  in  rare  instances  be 
inflamed  without  either  of  the  foregoing  complications. 

Inflammation  of  the  middle  ear  is  in  most  cases  preceded  by  pharyn- 
gitis, and  is  thus  affected  by  invasion  through  the  Eustachian  tube.  It 
may  be  produced  by  traumatism,  or  the  initial  lesion  may  be  situated 
within  the  cavity  of  the  tympanum,  or  in  the  mastoid  cells,  which  com- 
municate with  the  cavity.  Otitis  media  is  not  uncommon  in  children  as 
a  sequel  of  scarlatina  or  rubeola. 

The  earliest  symptom  of  this  affection  is  pain  of  a  severe  character, 
accompanied  by  partial  arrest  of  hearing.  Fever  is  present,  and  may 
be  preceded  by  a  chill  or  rigors.  When  suppuration  occurs,  and  the 
mastoid  cells  are  involved,  the  j^ain  is  intensified  and  the  feln-ile  move- 
ment at  times  very  high.  In  a  case  of  this  character  which  I  saw,  and 
in  which  the  operation  of  puncture  and  trephining  the  mastoid  process 
had  been  delayed,  fatal  pyjemia  occurred.  In  specimens  of  blood  taken 
from  this  patient  just  before  death,  the  red  blood-disks  were  seen  to  be 
filled  with  bacteria.  Percussion  with  the  finger-tip  over  the  mastoid 
region  exaggerates  the  sense  of  pain.  Ui^on  examination  with  the  oto- 
scope and  head-light,  the  drum  of  the  ear  will  be  seen  to  be  more  oijaque 
than  normal,  its  vascularity  increased  and  bulging  toward  the  meatus  if 
there  is  pus  in  the  middle  ear. 

The  treatment  of  otitis  media  should  be  directed  to  the  arrest  of  the 
inflammatory  process  by  warm  fomentations,  liy  the  ap])lication  of 
leeches  to  the  temples  and  mastoid  region.  Quinia,  iron,  stimulants, 
and  well-selected  diet  are  indicated  in  the  effort  to  improve  the  general 
condition  of  the  patient.  It  is  of  great  moment  that  the  tension  of  the 
tympanum  and  of  the  mastoid  cells  should  be  relieved  early  in  the 
progress  of  the  disease,  and,  even  when  there  is  a  doubt  as  to  the  pres- 
ence of  pus,  explorative  puncture  of  the  membrana  tympani  should  be 


Fio.  43G. — Politzcr's  tympamim-perfovator,  aiiKular. 

made.  The  operation  is  witlKuit  danger,  is  not  difficult  of  accomplish- 
ment, and,  even  when  suppuration  has  not  occurred,  ^^^ll  often  give 
great  and  immediate  relief.     A  proper  instrument  for  this  procedui*e  is 


396  A  TEXT-BOOK   ON   SURGERY. 

shown  in  Fig.  43G.  The  silver  six-culmii  nml  reflected  light  sliould  be 
employed  so  as  to  bring  the  ni('iiil)r;ine  into  plain  view,  and,  while  the 
head  of  the  patient  is  held  motionless,  the  j)oint  of  the  perforator  is 
carried  against  the  drum  on  its  posterior  inferior  quadrant,  and  barely 
pushed  thiougli.  The  puncture  should  not  be  more  than  cme  eighth  of 
an  inch  in  length.  If  there  shall  have  been  an  effusion  of  serum,  or  if 
pus  is  present  upon  the  withdrawal  of  the  instrument,  a  small  quantity 
<)f  fluid  will  escape  through  the  jtuncture.  Tf  necessary  to  the  estab- 
lishment of  free  drainage,  the  opening  may  lie  ejilarged. 

AVhen  otitis  virdia  is  complicated  with  inflammation  and  suppuration 
of  the  mastoid  cells,  and  when  the  communication  with  the  tympanum 
is  not  sufficient  to  give  ready  discharge  to  the  products  of  inflammation 
into  the  middle  ear,  and  thence  out  through  the  puncture  in  the  nicm- 
hrana  tympani,  the  cells  should  be  opened  and  drainage  secured  at  once 
by  removing  the  outer  shell  of  the  mastoid  process.  In  children  this  pro- 
cedure is  not  always  necessary  on  account  of  the  very  thin  shell  of  Ixme 
which  incloses  the  cavity  of  the  mastoid  antrum,  and  which  readily 
gives  way  and  allows  egress  to  the  pus  formed  within.  In  drilling  or 
trephining  the  mastoid  cells,  proceed  as  follows  : 

The  skin  over  and  near  the  mastoid  process  should  be  shaved  and 
cleansed,  and  a  free  incision  made  in  a  vertical  direction,  the  center  of 
the  cut  being  opposite  the  center  of  the  auditory  meatus  and  one  fourth 
of  an  inch  from  the  posterior  wall  of  the  bony  canal.  If  any  difficulty 
is  exjjerienced  in  lifting  and  reflecting  the  integument,  a  short  trans- 
verse cut  should  be  made  backward  from  the  middle  of  the  perpendicu- 
lar incision.  The  iieriosteum  should  be  scratched  off  at  the  point  where 
the  bone  is  to  be  perforated,  unless  necrosis  has  already  occurred  and 
only  a  thin  shell  of  bone  remains.  In  this  condition  the  shell  should 
be  lifted  off  and  the  cells  cleaned  out.  When  the  bone  has  a  henlthy 
aj^pearance  on  the  exterior  it  should  be  cut  through  with  a  trephine, 
gouge,  chisel,  or  drill.  The  trephine  em])loyed  should  not  be  more  than 
a  quarter  of  an  inch  in  diameter,  and  the  center  of  the  hole  made  (no 
matter  what  instrument  is  employed)  should  not  be  farther  than  a  quar- 
ter of  an  inch  posterior  to  the  wall  of  the  auditory  canal  on  account  of 
the  proximity  of  the  lateral  sinus  and  the  veins  of  the  diploe  which 
empty  into  it.  After  the  instrument  has  traveled  about  an  eighth  of 
an  inch  into  the  bone  it  should  be  removed  and  the  circular  track  in- 
spected. Tlie  entrance  to  the  cells  will  be  indicated  by  a  slight  haemor- 
rhage, and,  if  abscess  is  present,  by  a  few  drops  of  pus.  As  soon  as 
the  bleeding  is  seen  the  button  of  bone  should  be  lifted  by  the  elevator 
and  the  remaining  cancellous  tissue  scooped  out  with  the  iron  spoon  or 
the  scalloped  gouge.  The  abscess  should  be  irrigated  with  a  l-to-3000 
sublimate  solution,  and  the  wound  dressed  with  a  loose  sublimate  gauze 
dressing.  If  the  trei^hine  is  not  used,  the  scalloped  gouge  (Fig.  69),  the 
bone-drUl  (Fig.  72),  the  scoop  (Fig.  68),  or  the  chisel  and  mallet  may  be 
substituted.  If  (as  has  occurred  in  several  instances)  marked  bleeding 
occurs — probably  from  wounding  some  large  vein  near  its  entrance  into 
the  sinus — it  may  be  arrested  by  packing  with  sublimate  gauze  and 


THE  NOSE.  397 

the  drainage  established  a  few  hours  later,  when  the  haemorrhage  has 

ceased,  by  substituting  a  loose  dressing. 


The  Nose. 

Acquired  Lesions. — Fracture  of  the  bones  of  the  nose  has  been 
already  considered. 

HJpistaxis,  or  liferaorrhage  from  the  nose,  is  often  severe  enough  to 
demand  surgical  interference.  The  bleeding  may  at  times  be  ai-rested 
by  diminishing  the  blood-pressure  in  the  vessels  of  the  nose  by  ligation 
of  the  extremities.  This  consists  in  ajsplying  an  elastic  bandage  (or  an 
ordinary  roller,  if  the  rubber  can  not  be  obtained)  around  the  thighs  and 
arms  close  to  the  trunk,  and  making  the  pressure  strong  enough  to  arrest, 
in  great  part,  the  return  of  blood  through  the  veins  without  arresting  the 
circulation  in  the  arteries.  "When  the  hfomorrhage  ceases  the  ligatures 
should  be  gradually  loosened,  so  that  the  volume  of  blood  which  has 
been  confined  in  the  extremities  may  not  be  too  suddenly  returned  to 
the  heart.  Plugging  or  tamponing  the  nares,  if  properly  done,  will 
succeed  if  all  other  methods  fail.  First,  determine  accurately  the  nostril 
in  which  the  bleeding  is  occurring.  Take  a  piece  of  tine  sponge  at  least 
an  inch  in  diameter  when  dry  (and  it  should  be  introduced  without  being 
moistened,  so  that  when  in  position  in  the  posterior  nares  it  will  expand 
as  the  blood  moistens  it),  and  tie  around  its  center  three  strong  silk 
threads.  A  soft  catheter  or  bougie  is  now  introduced  into  the  nostril 
from  the  front,  keeping  the  point  of  the  instrument  well  on  the  floor  of 
the  nose.  As  soon  as  the  end  is  seen  or  felt  behind  the  soft  palate,  it  is 
drawn  out  at  the  mouth  by  the  forceps  or  lingers.  Two  of  the  three 
threads  are  attached  to  the  point  of  the  instrument,  which  is  then  pulled 
back  through  the  nostril.  When  the  threads  come  out  of  the  nose  in 
front  they  are  seized  by  the  fingers  of  one  hand  while  the  sponge  is  care- 
fully guided  into  position  hehind  the  soft  palate  with  the  other.  Once 
well  in  the  posterior  naris  it  is  held  in  position  and  made  to  exert  the 
necessary  compression  by  tying  the  two  anterior  strings  over  a  softened 
sponge  packed  into  the  nostril  in  front.  The  third  thread  is  brought  out  of 
the  mouth,  and  is  to  be  used  in  dislodging  the  tampon  when  the  ha^nor- 
rhage  has  ceased.  Lint,  soft  rags,  or  cotton  may  be  used  for  plugs  when  a 
sponge  can  not  be  obtained.  A  long  probe  or  a  loop  of  st)ft  wire  may  be 
used  instead  of  the  bougie.  The  application  of  a  4-to-8  per  cent  solution 
of  cocaine  hydi-ochlorate  to  the  mucous  membrane  of  the  nose  may  prove 
useful  as  a  hsemostatic,  since  Bosworth  has  demonstrated  that  it  causes 
marked  diminution  in  the  caliber  of  the  vessels  of  the  lining  membrane. 

Foreign  Bodies. — Buttons,  seeds,  and  other  substances  are  often 
lodged  in  the  cavity  of  the  nose.  The  usual  seat  of  lodgment  is  in  the 
anterior  part  of  the  inferior  meatus,  or  between  the  lower  turbinated 
bone  and  the  se])tum,  and  occasionally  they  are  pushed  beyond  this  into 
the  middle  meatus.  When  allowed  to  remain,  infiamniatitm  of  the  lining 
membrane  always  ensues,  and  ostitis  is  not  infrequent. 


398  A  TEXT-BOOK   ON   SURGERY. 

The  diagnosis  depends  ujioii  ]llly^i(•;l]  exploration  by  means  of  the 
head-mirror,  a  strong  light,  anil  the  metal  i)r()l)e.  Tlie  presence  of  a 
body  lodged  in  the  nasal  cavity  may  be  at  times  indicated  by  the  change 
of  the  voice  from  its  natural  to  a  nasal  tone.  Removal  is  urgent,  and 
may  be  effected  by  inspiration  thnmgh  the  month  and  forced  ex])iration 
through  the  nose,  with  the  mouth  and  nostril  of  the  unaffected  side 
closed.  In  adults  the  act  of  sneezing  will  sometimes  succeed  in  dislodg- 
ing the  substance.  A  strong,  slender  forceps,  bent  at  an  angle  so  that 
the  hand  of  the  operator  will  not  shut  out  the  light,  is  the  most  suit- 
able instrument  to  be  employed  in  its  removal.  When  the  body  is 
lodged  well  back  it  may  be  pushed  through  into  the  pharynx  and  eject- 
ed from  there. 

BhinoUtes^  or  lutsnl  calculi^  are  occasionally  found  in  these  cavities. 
It  is  pi-obable  that  they  come  from  the  lachrymal  apparatus,  si«ce  they 
are  found  in  the  immediate  neighborhood  of  the  entrance  of  the  nasal 
duct.  Moreover,  ducJirijolifes,  or  lachrjMual  concreticms,  are  not  very 
infrequent  in  the  lachi-ymo-nasal  apparatus.  These  bodies  should  be 
removed  with  the  forceps  as  soon  as  discovered. 

Neojila-rins. — The  most  frequent  variety  of  tumor  within  the  nasal 
cavity  is  the  myxoma,  or  so-called  gelatinous  poli/j>u.s.  Next  in  order 
of  frequency  is  X\\e  fibroma,  ov  fibrous  pohjinis.  Both  of  these  belong 
microscopically  to  the  connective-tissue  tumors,  the  myxomata  being 
allied  to  the  embryonic,  the  fibromata  to  the  more  developed  connective- 
tissue  tumors.  Papillomata,  or  warts,  are  not  infrequently  seen  at  the 
edges  of  the  mucous  membrane  of  the  nostrils.  Lastly,  there  may  be  a 
general  hypertrophy  of  the  mucous  meml)rane  of  the  nose,  causing  a 
tumefaction  of  the  turbinated  tufts,  and  partial,  or  may  be  complete, 
occlusion  of  the  nares. 

Gelatinous  nasal  polypi  are  xisually  pear-shaped,  the  bulk  of  the 
tumor  tending  toward  the  floor  of  the  nose.  The  pedicle  is  attached  to 
one  of  the  thick  velvety  tufts,  most  frequently  in  the  upper  or  middle 
meatus.  There  may  be  a  single  tumor,  although  the  rule  is  for  them 
to  be  multiple.  They  are  of  light  grayish  color,  and  are  covered  by  a 
mucous  exudation. 

The  symptoms  are  chiefly  those  due  to  pressure  and  obstruction  of  the 
nares.  Changes  in  the  voice  are  not  marked  until  the  presence  of  the 
tumor  has  been  suspected  from  pressure  and  imtation.  This  ii-ritation 
gives  rise  to  an  excessive  secretion  and  discharge  from  the  nose,  and 
occasionally  to  prolonged  and  violent  fits  of  sneezing. 

The  diagnosis  may  be  rendered  positive  by  physical  exploration. 
The  shrinkage  of  the  turbinated  tufts,  following  the  local  use  of  cocaine 
hydrochlorate,  renders  inspection  more  easy. 

Treatment. — The  only  rational  method  of  treatment  is  removal  and 
destruction  of  the  pedicle  and  contiguous  mucous  membrane.  Avulsion 
may  be  effected  by  seizing  the  growth  with  a  long,  delicate  polypus-for- 
ceps, and  twisting  the  tumor  around  until  the  pedicle  is  wrung  off,  then 
applying  pure  nitric  acid  or  the  galvano-cautery  to  the  stump.  The 
wire  ecraseur  or  snare  of  Jarvis  is  greatly  to  be  preferred  (Fig.  437) 


THE  NOSE. 


399 


After  the  wire-loop  has  been  passed  around  the  tumor,  and  slipped  up 
to  the  pedicle,  it  should  be  slowly  tightened,  since  by  this  method  the 
danger  of  haemorrhage  which  always  follows  the  use  of  the  forceps  is 
avoided.     From  one  to  two  hours  may  be  consumed  in  the 
division  of  the  growth,  the  screw  being  turned  from  time  to 
time.     Nitric  acid  or  the  cautery  should  be  applied  to  the 
stump  in  all  cases,   since  without  this  recurrence  is  almost 
certain. 

Fibro77iata,  or  fibrous  polypi,  are  much  less  frequent  than 
the  myxomata.  As  a  rule  they  are  deeper  situated.  They  re- 
quire the  same  treatment  as  above  given.  Occasionally  large 
tumors  of  the  nasal  cavities  require  for  their  complete  removal 
section  of  the  nasal  and  superior  maxillary  bones.  In  this 
procedure  the  skin  and  periosteum  should  be  left  intact,  and 
osteoplasty  performed  in  order  to  prevent  necrosis. 

PaplUoinata,  or  limits,  which  occur  at  the  junction  of  the 
mucous  membrane  of  the  nares  with  the  integument,  should 
be  clipped  off  with  curved  scissors  and  their  bases  burned  with 
l^ure  nitric  acid. 

Hypertrophy  of  the  turbinated  tufts  may  exist  to  such  an 
extent  as  to  demand  interference.  Such  enlargement  should 
be  treated  exactly  as  one  would  treat  true  polypus. 

Fissures  of  the  nares  may  be  relieved  by  the  repeated  local 
use  of  the  lunar-caustic  pencil. 

Oz(ena. — Ozsena  is  the  name  given  to  a  chronic  intlamma- 
tion  of  one  or  more  of  the  nasal  cavities,  or  the  sinuses  com- 
municating with  them.  It  may  be  confined  to  a  process  of 
ulceration  of  the  soft  tissues  alone,  but  not  infrequently  there 
is  an  ostitis.  Syphilitic  ozfena  is  probably  the  most  common 
form.  It  frequently  occurs  with  other  dyscrasise.  It  is  accom- 
panied by  a  fetid  odor  and  a  muco-purulent  discharge,  par- 
tially liquid  and  partially  solid.  Atrophy,  or  destruction  of 
the  turbinated  tufts,  is  not  infrequent,  so  that  ther-e  is  abnor- 
mal space  within  the  nares. 

The  treatment  is  local  and  general.  The  removal  of  dis- 
eased or  dead  bone  is  imperative,  and  irrigation  with  the 
weaker  sublimate  or  boracic-acid  solutions  should  be  regularly 
made. 

Dobbell's  solution  will  be  found  of  use :  Carbolic  acid, 
gr.  x;  biborate  and  bicarbonate  of  soda,  each,  3j;  glycerin, 
3  X  ;  to  this  add  water  to  make  §  x.  This  should  be  used  five 
or  six  times  a  day  as  a  douche.  The  general  condition  of  the 
patient  should  ])e  improved  by  the  administration  of  well- 
selected  tonics  and  food,  and  by  out-of-door  life. 

Superficial  epithelioma,  situated  upon  the  nose  or  face,  should  be 
destroyed  by  the  application  of  Marsden's  paste.  It  is  made  of  arsenioi;s 
acid  and  powdered  gum  acacia,  equal  parts,  with  enough  water  to  make 
a  fairly  soft  paste.    It  may  be  left  on  fi-om  twelve  to  twenty-four  hours — 


Fio.  4sr.- 

Jarvis's 
snare. 


400  A  TEXT-ROOK   ON     SURGERY. 

as  long  as  the  patient  can  endure  the  pain.  ,  Poultices  are  applied  after- 
ward. If  the  first  applirarion  is  not  sufficient,  it  sliould  be  repeated. 
The  loss  of  substance  cau.sed  by  the  destructive  action  of  the  paste  may 
be  repaired  by  a  plastic  operation  ;  but  this  should  not  be  done  until 
cicatrization  has  occurred. 

The  frontal  sinus  may  be  involved  in  some  of  the  diseases  which 
affect  the  nose.  New  growths,  abscess,  or  ostitis  may  demand  the  appli- 
cation of  the  trephine  in  the  removal  of  a  neoplasm  or  dead  bone,  or  the 
evacuation  of  pus. 

Der/'af/on  of  the  nose  from  the  median  line  may  be  congenital  or 
acqtiired.  The  septum  alone  may  project  to  one  side,  or  the  entire  organ 
be  disjilaced  laterally  or  upward.  When  the  distortion  is  due  to  malfor- 
mation of  the  bones,  these  must  be  forced  into  position,  with  or  without 
fracture. 

Deviation  of  the  soft  parts  which  form  the  tip  of  the  nose,  sufficient 
to  produce  deformity,  may  be  corrected  by  the  method  of  Prof.  John  B. 
Roberts.  In  case  the  tip  of  this  organ  is  turned  to  the  right,  proceed  as 
follows :  "With  a  scalpel  perforate  the  cartilaginous  septum  at  its  upper 
and  back  part,  and  make  a  long  incision  through  it,  in  a  direction  down- 
ward and  forward.  This  incision  should  allow  the  operator  to  push  the 
whole  cartilaginous  portion  of  the  nose  to  the  left.  To  retain  the  parts 
in  this  position,  introduce  a  steel  pin,  about  one  inch  and  a  fourth  long, 
into  the  right  nostril,  and  pass  it  completely  through  the  anterior  and 
upper  segment  of  the  divided  se]:)tum,  near  the  columella.  By  carrying 
the  head  of  the  pin  to  the  left,  the  anterior  portion  of  the  nose  will  be 
also  carried  in  this  direction,  and  may  be  retained  by  imbedding  the 
point  of  the  pin  deeply  in  the  immovable  cartilaginous  septum  and  mu- 
cous membrane  at  the  back  of  the  left  naris.  The  pin  may  be  removed 
as  soon  as  fii-m  adhesions  have  formed,  usually  in  from  five  to  ten  days. 

Deviations  of  the  septum  alone  may  be  corrected  by  the  same  method. 

Hiipertrophy  of  the  nose,  due  to  increased  vascularity,  may  be  cor- 
rected by  repeated  incisions  across  the  track  of  the  enlarged  vessels,  by 
galvano-puncture,  or  by  causing  their  obliteration  by  injections  of  50-per- 
cent carbolic-acid  solution,  as  for  nacus. 


Plastic  Surgery  of  the  Nose. 

Loss  of  substance  may  occur  from  the  accidental  or  surgical  ablation 
of  all  or  a  portion  of  this  oi'gan,  or  from  its  destruction  by  disease.  The 
diseases  which  most  frequently  produce  loss  of  substance  are  syphilis 
and  lupus.  Carcinoma,  sarcoma,  elephantiasis,  or  any  neoplasm,  may  in- 
volve the  nose  and  cause  loss  of  tissue  in  their  removal,  but  lupus  locates 
itself  by  preference  here,  while  one  of  the  most  common  lesions  of  tertiary 
syphilis  is  necrosis  of  the  cartilages  and  bones  of  the  nose,  resulting  in 
great  disfigurement.  Occasionally  sloughing  occurs,  from  the  i)resence 
of  a  phagedenic  syphilide  during  the  second  stage  of  this  disease.  Hhis 
accident  occurred  in  the  patient  from  which  Fig.  447  was  taken. 


PLASTIC   SURGERY  OF   THE  XOSE. 


401 


RTiinoplasfy  may  be  partial  or  complete.  Complete  rhinoplasty  is 
performed  when  the  skin,  cartilages,  and  bone  of  the  nose  have  been 
carried  away.  In  sucli  cases  nothing  remains  but  an  Lrregnlar  sunken 
pit,  leading  almost  directly  into  the  pharynx. 

The  operation  consists  (1)  in  paring  the  margins  of  the  opening  and 
the  integument  immediately  around  the  opening,  in  apposition  to  which 
the  transplanted  flap  is  to  be  brought ;  (2)  in  the  transportation  of  a 
properly  shaped  piece  of  skin,  with  its  underlying  tissues,  from  its  nor- 
mal to  the  new  position. 

Tlie  flap  may  1:)e  taken  entirely  from  the  forehead,  or  one  half  from 
each  cheek,  or  from  the  arm.  One  of  the  most  frequent  causes  of  failure 
in  this  operation  is  the  caving  in  of  the  ridge  of  the  new  nose,  and,  in 
order  to  better  support  this  part,  the  end  of  one  of  the  fingers  may  be 
iitilized,  as  follows  : 

First  Method — Coinpldc  BTilnoplasty  from  tlie  Foreliead  and  Finger. 
— Remove  the  naU  and  matrix  of  one  finger  of  the  left  hand,  split  and 
dissect  up  the  integument  on  the  palmar  surface  of  this  finger,  as  far  back 
as  the  last  interphalangeal  articulation,  and  sew  this  to  the  already 
freshened  edges  of  the  nasal  opening.  The  arm,  hand,  and  head  should 
now  be  immovably  fixed  in  a  plaster-of -Paris  dressing,  in  which  position 
it  remains  for  about  four  weeks.  "When  the  circulation  is  freely  estab- 
lished between  the  vessels  of  the  face  and  the  transplanted  finger,  the 
latter  should  be  amputated  at  the  first  or  second  interphalangeal  articu- 
lations, as  may  be  necessary  to  have  it  of  suflicient  length  to  support 
the  covering  of  integument.  After  several  weeks'  delay,  to  assure  the 
permanent  vitality  of  the  transplant- 
ed phalanx,  a  flap  may  be  turned 
from  the  foi'ehead  to  the  nose,  as 
follows  : 

Cut  a  piece  of  chamois-skin,  or 
soft,  thin  leather,  of  the  shape  rep- 
resented in  Fig.  438.  Adjust  this 
to  the  line  of  the  nasal  cavity,  to  see 
if  it  is  large  enough  and  of  proper 
shape.  Bear  in  mind  tlie  following 
points:  1.  The  flap  once  dissected  up 
tends  to  contract.  It  should  there- 
fore be  sliglitly  larger  than  a  pattern 
which  fits  exactly.  2.  The  isthmus 
{fh  Fig.  438)  must  not  ))e  too  nan-ow, 
for  fear  that  the  vitalitj-  of  the  flap 
may  be  insufficient.  It  should  al- 
ways be  cut  so  as  to  include  the  an- 
gular artery.  B.  The  distance  from 
the  isthmus  id)  to  {e  e),  where  the 
lower  edge  of  the  new  no.se  is  to  be,  should  be  considerably  less  than  the 
distance  from  d  to  a  c,  in  order  to  prevent  tension  of  the  flap  and  inter- 
ference with  the  cii-culation  through  the  pedicle,  d.     Lay  the  pattern  on 

S6 


Fio.  4-38.— I  After  Linliart.) 


402 


A  TEXT-BOOK   ON   SURGERY. 


the  forehead  and  outline  the  flap  by  making  punctures  at  intervals  of 
every  fourth  of  an  inch  along  its  edges.  The  incision,  made  through  all 
the  tissues  down  to  the  periosteum,  sliould  begin  at  d  and  be  carried  to 
a  c  c  a,  and  tlieu  dt)\vn  to  a  poiut  near  the  eyebrow,  at  (/,  in  tlie  line  of 
the  freshened  margin  of  the  nasal  cavity.  The  smaller  incisions  in  the 
flap  a  b  or  c  b  are  made  to  provide  for  the  septum  and  al;t;  of  the  new 
nose.  If  the  linger  has  been  grafted  for  the  support  of  the  flap,  tlie  in- 
cisions of  Labat,  cb,  cb,  will  suffice ;  if  not,  those  of  Lin  hart,  a  b,  a  b, 
will  give  a  doubly  folded  septum,  and  one  less  likely  to  f;dl  or  cave  in. 
The  flap  is  now  dissected  up  from  the  periosteum  as  far  as  the  pedicle, 
when  it  is  turned  down  and  sewed  into  position  with  tine  silk  sutures. 
The  secondary  flap  for  the  septum  is  first  doubled  on  itself,  and  then 
bent  in  at  a  right  angle  to  the  axis  of  the  nose,  and  stitched  down,  as 
shown  in  Fig.  439,  to  the  center  of 
the  lowest  portion  of  the  nose,  just 
above  the  middle  of  the  upper  lip, 
while  the  ahe  are  also  folded  in  and 
sewed,  as  represented  in  the  same 
cut.     The  operation  ,is   completed 


Flu.   i,.'.  — (Aiier  Lialiiirt.) 

when  the  entire  flap  has  been  ac- 
curately stitched  to  the  freshened 
edges  of  the  cavity,  as  shown  in 
Fig.  440.     Pieces  of  rubber  tubing 


Fio.  440. — (Alter  M.-ilgaigne.) 


may  be  inserted  in  the  nostrils  to 
hold  the  alaj  in  position.     The  upper 

part  of  the  wound  on  the  forehead  is  drawn  as  near  together  as  can  be 
done,  with  silk  or  silver-wire  sutures,  and  a  sublimate  or  iodoform  gauze 
dressing  is  api^lied.  No  pressure  must  be  exercised  upon  tlie  pedicle,  or 
flap,  which  should  be  loosely  enveloped  in  the  dressing.  In  about  two 
weeks  the  circulation  will  have  been  sufficiently  established  between  the 
flap  and  the  edges  of  the  cavity  to  permit  the  secti(m  of  the  pedicle,  the 
stump  of  which  is  used  in  filling  up  the  gap  upon  the  forehead.  In  re- 
turning the  pedicle  to  its  original  position,  it  is  advisable  to  scra]ie  out 
the  granulation-tissue  in  the  bottom  of  the  wound,  so  that  the  returned 
portion  will  sink  to  the  proper  level. 

Among  other  methods  of  performing  complete  rlnnoplasty  is  that 
of  Diefi'enbach,  as  shown  in  Fig.  441,  or  that  of  Koenig,  Fig.  442,  in 
which  the  pedicle  is  somewhat  wider  than  in  the  other  flaps.  The  flap 
of  Langenbeck  is  shown  in  Fig.  443.  These  various  oi^era  tions  of  trans- 
planting the  flap  from  the  forehead   are  modifications  of  the  Hindoo 


PLASTIC   SURGERY  OF  THE  NOSE. 


403 


Fio.  441.— Dieffenbach's  methoJ.     (After  Linhurt.) 

method.  Fig.  444  represents  a  rhino- 
plasty done  by  a  Hindoo  surgeon  in 
1793. 

Second  Method — Complete  Rhino- 
plasty from  the  Arm. — Freshen  the 
margins  of  the  nasal  cavity  as  before. 


Fio.  443. — Langenbeck's  incision.     (After  Koenig. ) 


Fig.  Hi. — Koenig's  metliod.     (.Vftcr  Koenig.) 


Fio.  444. — (.\fter  Szymanowsky.) 


Transplant  a  portion  of  the  finger  as  before  described,  if  the  septum  nasi 
has  completely  disappeared.  Place  the  palm  of  the  hand  on  the  top  of 
the  head,  Fig.  445,  so  that  the  anterior  surface  of  the  humeral  region 
will  be  in  close  proximity  to  the  face.  Calculate  the  length  and  breadth 
of  the  flap  required  to  be  raised  from  the  arm,  and  outline  it  with  ink. 
Fit  a  strong  wire  cuirass  or  the  upper  half  of  Bauer's  wire  breeches  com- 
fortably and  securely,  so  that  the  head  and  neck  may  be  held  immovable. 
Or  apply  a  plaster-of-Paris  jacket,  which  shall  cover  the  head.  Mold  a 
strip  of  one-quarter-inch-thick  gntta-percha  to  the  arm  and  forearm,  or, 
if  this  material  can  not  be  obtained,  sole  leather  or  shellac  may  be  sub 


404 


A  TEXT-HOOK   ON  SURGERY. 


stituted,  so  that  with  the  hand  on  the  occiput  and  the  interparietal 
suture,  the  strip  may  be  fitted  to  the  anterolateral  aspect  of  the  corset 
and  along  the  arm,  forearm,  and  hand,  as  in  Fig.  445.  Next  dissect  the 
integument  from  the  delt(»id  region  down  toward  the  elbow,  making  it 

extra  long  and  wide,  and  lifting  every- 
thing down  to  the  deep  fascia.  When  the 
li;emorrhage  has  ceased,  di'ess  the  wound 
in  the  arm  with  sublimate  gauze,  apply 
the  gutta-percha  mold,  lix  it  upon  tlie  cor- 
set with  a  tight  roller,  fasten  it  and  the 
underlying  hand  to  the  skull-piece  or 
helmet  {a  a.  Fig.  445)  and  accessory,  sup- 
porting strips  of  strong  adhesive  plaster, 
as  at  b.  Lastly,  stitch  the  edges  of  the 
flap  to  the  freshened  margins  of  the  nasal 
rim.  The  circulation  between  the  face 
;ind  skin  of  the  arm  should  be  sufficiently 
established  from  the  tenth  to  the  four- 
teenth day  to  permit  section  of  the  Hap. 

Since  the  skin  of  the  arm  is  very  thin, 
and  after  transplantation  is  apt  to  shrink 
away,  it  is  a  wise  precaution  to  dissect 
up  the  Hap  from  the  shoulder  and  arm, 
making  it  longer  than  may  at  first  appear 
necessary— and  to  do  this  eight  or  ten  days  before  the  arm  is  fastened  in 
the  immovable  apparatus.  The  liap  in  this  way  shrinks,  and  is  covered 
with  granulations,  in  which  condition  union  with  the  integument  of  the 
face  is  accelerated  and  assured. 

Wlien  the  vascular  connection 
is  safely  established,  the  pedicle  is 
cut,  the  arm  released,  and  the  flap 
shaped  and  stitched  in  position,  as 
in  the  preceding  operation. 


Fio.  445.— (After  Liiiliart.) 


Fig.  44G. — (After  Szymanowsky.) 


Fig.  447. 


Wutzer  took  the  integument  from  the  forearm  ;  Fabrizzi  from  near 
the  elbow  (Fig.  446). 


PLASTIC   SURGERY   OF   THE  NOSE. 


405 


Partial  Rhinoplasty. — 

When  there  is  only  a  par- 
tial  loss   of   substance   the 

operation    is   less   difficult, 

and  the  prospect  of  success 

(greater.     When  one  ala  is 

involved,  as  shown  in  one 

of  my  cases  (Fig.  447),  tlie 

iiap  may  be  made  from  the 

cheek   (Fig.   448).     In   this 

patient  I  trimmed  the  cica- 
tricial edges  of  the  scar  and 

turned  a  flap,  as  indicated 

by   the   dotted    lines,    and 

stitched  it  to  the  nose.    The 

wound  in  the  face  was  par- 
tially   closed    by    sutures. 

The    pedicle    was    divided 

on  the  fourteenth  day  and 

turned  back  into  the  wound, 

the     granulations     having 

been     previously     scraped 

out.     Or   the  flap  may  be 

l)orrowed  from  the  side  of 

the  cheek,  leaving  the  ped- 
icle above,  as  in  Fig.  450. 

When  the  tip  of  the  nose  is  eroded,  the  method  indicated  in  Fig.  451 

should  be  adopted.     The  broad  end  of  the  flap  is  split ;  the  center  strip 

(a)  is  for  the  septum,  while 
those  at  6  6  are  to  complete 
the  eroded  alse. 


Flo.  449. — Transpliinteil  portion  in  the  new  position  after 
diviMon  and  return  of  the  pedicle. 


AYhen  in  the  removal  of 
small  neoplasms  the  ala  nasi 
is  perforated,  the  wound  may 


406 


A  TEXT-BOOK   ON  SURGERY. 


be  closed  by  sutures,  or  the  gap  may  be  filled  by  a  small  graft  of  skin 
lifted  entirely  from  the  arm  or  abdomen,  and  transi)lante(l  upon  the  nose. 

Operations  vi  minor  im- 
portance are  at  times  per- 
fonned  to  correct  lesser  de- 
formities. 


Fio.  452.— (After  Liiiliart.) 


¥iV 


Fig.  453.— (After  Linhart.) 


^-^' 


i;>^ 


Fig.  451.— (After  Liiihart.) 


When  the  alee  are  too  thick, 
elliptical  pieces  may  be  ex- 
cised and  the  edges  closed,  as 
in  Figs.  452  and  453.  If  the 
tip  of  the  nose  is  too  pointed 
and  upturned,  it  may  in  part 
be  corrected  by  exsecting  a  triangular  piece  from  the  septum  and  closing 
the  gap  with  sutures. 

Congenital  Lesions  of  tlie  Nose. — Occasionally  the  lateral  halves  of 
the  nose  fail  to  unite,  resulting  in  the  deformity  known  as  bifid  nose. 
There  may  be  partial  or  complete  absence  of  this  organ,  or  when  present 
the  nares  may  be  occluded,  or  it  may  be  complicated  with  the  extreme 
cases  of  hare-lip.  The  operative  procedure  for  the  relief  of  this  last 
deformity  will  be  given  in  connection  with  congenital  cleft  of  the  lip. 
Occlusion  of  the  nares  may  be  relieved  by  cutting  through  the  mem- 
brane in  the  direction  of  the  normal  opening.  For  the  correction  of 
forked-nose,  or  the  absence  of  this  organ,  no  fixed  rule  of  practice  can  be 
laid  down. 


The  Lips  and  Cheeks. 


WounrJs. — Accidental  wounds  of  the  lips  are  usually  incised  or  lacer- 
ated. If  badly  torn,  the  ragged  edges  should  be  smoothly  trimmed, 
washed  with  sublimate  solution,  and  secured  with  interrupted  silk 
sutures.  When  the  wound  is  through  the  entire  thickness  of  the  lip, 
the  sutures  should  include  the  mucous  membrane.  A  very  fine  suture 
or  pin  should  be  used  in  the  vermilion  border  to  insure  absolute  approxi- 


THE  LIPS  AND   CHEEKS.  407 

mation  here.  Adhesive  strips  are  not  reliable.  In  children  one  or  two 
pin-sutures  should  be  i:)referred,  as  they  best  resist  the  constant  strain 
to  which  sutures  of  the  parts  are  subjected  in  the  act  of  crying. 

Diseases  of  the  Lips. — Among  the  diseases  which  involve  the  lips 
and  the  contiguous  structures  are  epitJielioma,  liqjus,  papilloma,  noeims, 
cysts,  lipoma,  adenoma,  pTdegmon,  ulcers,  and  general  hyjjertrojjhg 
and  fissures. 

Epitlielioma. — One  of  the  most  frequent  causes  of  removal  of  portions 
of  the  lips  is  the  presence  of  epithelioma.  It  is  a  disease  of  middle  and 
old  age,  involves  usiially  the  lower  lip,  and  occurs  in  the  great  majority 
of  instances  in  males.  Ei:)ithelioma  may  attack  the  lip  without  any  ap- 
preciable cause,  but  in  most  cases  the  appearance  of  the  neoplasm  is 
preceded  by  prolonged  irritation  at  the  place  involved.  A  jagged  or 
projecting  tooth,  the  habitual  nse  of  a  pipe-stem  or  cigar,  are  frequent 
causes  of  this  disease.  It  will  also  result  from  the  initation  caused  by 
chronic  tissure  or  ulcer  of  the  lip. 

Symptoms. — It  begins  as  a  small  ulcer  with  rather  abrupt  margins,  in 
the  bottom  of  which  is  a  dirty  granulation-tissue  partially  hidden  by 
thin  pus.  In  its  earlier  stages  it  is  not  readily  distinguished  from  the 
benign  ulcer  which  is  found  upon  the  lip.  The  preceding  history  of  a 
prolonged  irritation  should  always  suggest  epithelioma,  especially  if  it 
occurs  after  the  age  of  thirty,  and  upon  the  lower  lip.  Ulcer  is  apt  to 
occur  in  one  of  the  scrofulous  or  tubercular  diathesis.  If  grave  doubt 
exists  as  to  its  malignant  nature,  the  application  of  the  solid  stick  of 
nitrate  of  silver  should  be  made.  An  ordinary  ulcer  will  heal  rapidly 
under  this  stimulus,  while  the  epithelioma  is  not  affected.  Labial  chancre 
may  be  differentiated  by  the  indurated  base,  which  is  characteristic  of 
this  lesion.  Adenitis  in  the  line  of  lymphatics  along  the  lower  jaw  comes 
on  in  the  earlier  stages  of  syiahilis,  while  in  epithelioma  the  sore  may 
exist  for  months  without  perceptible  enlargement  of  the  lymphatic 
glands.  In  syphilis  the  a^jpearance  of  the  eruption,  together  with  the 
history  of  the  case,  will  lead  to  correct  differentiation. 

Epithelioma  of  the  lip  is  a  dangerous  affection.  Left  alone,  it  de- 
stroys life  within  a  period  varying  from  one  to  four  years.  It  spreads  at 
times  with  rapidity,  eating  away  the  tissues  in  all  directions.  It  may 
confine  itself  to  the  soft  parts,  or  attack  the  maxillary  and  nasal  bones. 
Engorgement  of  the  submental,  sublingual,  submaxillary,  and  cervical 
glands  is  almost  inevitable  if  the  disease  is  not  extirpated  in  the  first  few 
months  of  its  historj^  The  glandular  enlargement  is  at  first  not  always 
due  to  metastasis,  but  may  result  from  simple  adenitis  following  the  in- 
flammatory process  in  the  margins  of  the  iilcer. 

Treatment. — The  early  excision  of  the  diseased  tissiie  is  imj>erative. 
The  knife  should  always  be  preferred  to  the  use  of  corrosive  substances. 
The  incision  should  be  wide  of  the  diseased  area — at  least  half  an  inch 
from  the  infiltrated  margin.  If  the  disease  has  existed  long  enough  to 
have  caused  lymphatic  enlargement,  the  infiltrated  glands  must  also  be 
extirpated. 

The  prognosis  as  to  a  permanent  cure  is  always  doubtful,  although 


408  A  TEXT-BOOK  ON   SURGERY. 

when  the  operation  is  performed  early  in  the  history  of  the  disease  a 
cure  may  be  effected.  In  ninny  cases  where  recurrence  after  ojx'ration 
is  ])robable,  life  may  be  prolonged  and  rendered  more  endurable  by  ex- 
cision of  the  nicer.  After  a  primary  excision  the  patient  should  be  kept 
under  close  oliservation,  and,  njion  the  rea])pearance  of  the  neoplasm  in 
the  scar  or  lymphatics,  a  second  operation  should  be  performed.  In 
1884  I  removed  a  large  number  of  infiltrated  glands  from  the  neck  of  a 
man  about  fifty  years  old,  who  had  had  an  epithelioma  of  the  lip  excised 
twelve  years  previous  to  that  date.  Five  years  after  the  lirst  operation  a 
gland  at  the  lower  edge  of  the  jaw  became  enlarged  and  was  extirpated. 
Six  years  later  the  glands  beneath  the  jaw  began  to  swell,  and  a  year 
later,  when  I  saw  him,  metastasis  had  seemingly  occurred  in  all  the 
lymi)hatics  as  far  down  as  the  lower  third  of  the  neck  on  one  side.  The 
infiltration  was  so  extensive  and  deep  that  it  took  two  operations,  each 
lasting  about  three  hours,  to  effect  the  removal.  The  examination  of 
the  glands  demonstrated  the  malignant  character  of  the  disease.  At 
this  date,  two  years  from  the  last  operation,  the  patient  is  living  and 
healthy. 

Lupus. — Lupus  erythematosus  and  vulgaris  usually  attack  the  tis- 
sues t)f  the  nose,  cheeks,  and  lips,  at  times  producing  extensive  loss  of 
substance.  The  erythematous  variety  is  first  seen  as  small  red  papules, 
lirojecting  slightly  above  the  epidermis,  and  covered  with  scales.  It  is 
a  disease  of  the  sebaceous  glands  and  ducts,  causing  chronic  inflamma- 
tion of  the  skin  and  atrojihy  of  all  the  elements  of  the  cutis.  Its  prog- 
ress is  slow,  and  the  prognosis  is  usually  favorable  when  the  disease  is 
confined  to  a  limited  area.  It  does  not  affect  the  general  health  of  the 
patient,  and  often  heals  spcmtaneonsly,  leaving  a  flat,  smooth  scar. 
^Vhen  disseminated  it  is  more  dangerous,  not  infrequently  ending  in 
fatal  complications.  The  treatment  requires  generous  diet,  tonics,  and 
out-of-door  life.  Among  the  local  agents  recommended  in  lupus  ery- 
thematosus is  green  soap,  which  should  be  sjn-ead  on  lint  and  pressed 
closely  upon  the  affected  part,  or  rubbed  in  with  the  finger  every  day. 
Prof.  A.  R.  Robinson,  in  addition  to  the  above,  also  recommends  a  10- 
per-cent  solution  of  oleate  of  mercury  brushed  over  the  diseased  surface. 

If  the  disease  does  not  yield  to  these  milder  measures,  the  sharp 
spoon  should  be  employed  and  the  broken-down  tissue  thoroughly 
scooped  out.  Emollients,  cold  applications,  or  poultices  may  be  used 
afterward,  according  to  the  recpiirements  of  the  case. 

Lupus  vulgaris  is  a  more  formidable  affection.  In  its  earlier  stages 
it  consists  of  a  number  of  soft  red  dots  in  the  deeper  layers  of  the  in- 
tegument, which  gradually  appear  as  papules  upon  the  surface.  The 
characteristic  lesion  is  the  infiltration  of  the  skin  with  an  abundant 
small  cell  new-growth.  It  is  believed  to  be  a  tuberculosis  of  the  skin. 
The  integument  breaks  down  and  is  cast  off  as  a  slough.  The  new- 
formed  cells  also  undergo  granular  metamorphosis,  and  disappear  with 
the  other  destroyed  tissues.  The  only  disease  likely  to  be  mistaken  for 
common  lupus  in  the  adult  is  epithelioma.  Lupus  begins  usually  in 
childhood,  while  epithelioma  is  exceedingly  rare  before  the  age  of  thirty. 


THE   LIPS  AND   CHEEKS.  409 

The  ulcer  of  lupus  is  not  so  painful  as  that  of  epithelioma,  nor  its  edges 
so  hard  and  elevated.  The  treatment  of  this  affection  is  often  unavail- 
ing. The  constitutional  treatment  is  the  same  as  for  lupus  erythemato- 
sus. Locally,  a  lU-per-cent  ointment  of  pyrogallic  acid,  spread  upon 
linen  and  closely  laid  upon  the  diseased  surface,  is  a  useful  i-emedy.  It 
should  be  applied  twice  daily  for  several  days,  and  then  poultices  or 
ointments  used  until  the  slough  is  removed.  In  certain  cases  it  is  ad- 
visable to  scrape  the  ulcer  well  with  the  sharp  spoon,  and  then  apply  the 
pyrogallic  acid  for  one  or  two  days. 

Nceous. — As  has  been  stated  in  the  article  on  diseases  of  the  vascu- 
lar system,  arterial,  capillary,  and  cutaneous  vascular  tumors  are  occa- 
sionally located  upon  the  lips  and  cheeks,  and  require  removal  by  the 
knife,  ligature,  or  injection.  Their  excision  often  causes  extensive  loss 
of  tissue.  When  situated  in  the  free  border  of  the  lips  or  nares,  the 
50-per-cent  carbolic-acid  injection  should  be  tried  before  excision  is  prac- 
ticed. 

Moles  are  less  formidable,  and  rarely  require  an  extensive  reparative 
operation  after  excision. 

Papilloma,  lipoma,  adenoma,  and  fibroma  do  not,  as  a  rule,  require 
extensive  incisions  and  loss  of  tissue  in  their  removal. 

Cystic  tumors  of  the  lip  are  not  infrequent,  occurring  as  spherical 
swellings  beneath  the  mucous  membrane.  They  are  caused  by  obstruc- 
tion of  the  duct  of  a  labial  follicle,  and  contain  a  thick,  ropy  fluid.  The 
treatment  involves  a  careful  and  thorough  excision  of  the  sac. 

Fissures,  or  "'■  chaps''''  of  the  lip  may  occur  independently  of  any 
constitutional  disease.  They  may  be  cured  by  a  local  astringent,  as 
alum,  or  caustic,  as  nitrate  of  silver,  applied  once  a  day  for  tvro  or  three 
days.  When  these  more  simple  remedies  are  without  avail,  excision 
should  be  practiced.  When  tissui-e  of  the  lip  is  allowed  to  remain,  and 
the  general  condition  of  the  patient  is  bad,  necrosis  of  the  mucous  mem- 
brane immediately  contiguous  ensues,  causing  a  grayish-red  ulcer.  The 
treatment  consists  in  the  local  use  of  astringents  and  the  improvement 
of  the  patient's  nutrition. 

Phlegmon  of  the  lip  is  rare.  It  is  a  painful  and  dangerous  affection. 
The  pathology  of  carbuncle  has  been  given.  The  proper  treatment  is 
early  and  free  incision  through  the  skin,  deep  fascia,  and  muscles,  and 
frequent  irrigation  with  strong  sublimate  solution. 

Hypertrophy  of  the  lip  is  occasionally  met  with.  It  may  be  confined 
to  the  mucous  and  submucous  tissues,  or  the  entire  thickness  of  the 
lip  may  be  involved.  It  occurs  usually  in  the  upper  lip,  but  may  be 
seen  occasionally  in  the  lower  lip.  When  extensive  enough  to  require 
operative  interference,  the  proper  method  is  to  dissect  out  in  the  long 
axis  of  the  lip  a  portion  of  the  tissue  between  the  skin  and  mucous 
membrane,  and  approximate  the  edges  of  the  wound  \y\{\\  silk  sutures. 

Hair  on  tlie  Lips  of  Women. — Permanent  epilation  may  be  effected 
by  introducing  into  the  follicle  of  each  hair  the  point  of  a  fine  platinum 
needle,  which  is  afterward  heated  by  the  galvanic  current.  The  employ- 
ment of  cocaine  renders  this  operation  painless. 


410 


A  TEXT-BOOK   ON   SURGERY. 


Reparative  Surgery  of  the  Lips. — A  plastic  operation  may  be  de- 
manded in  acquired  or  con'i'enital  lack  of  tissue  in  tiie  upper  li]).  In 
the  lower  lip  congenital  del'orniity  is  exceedingly  rare. 

Ilare-Lip. — Hare-lip  is  a  congen- 
ital defect  cansed  by  an  arrest  of  de- 
velojiment  in  the  tissues  which  form 


Fig.  455. 


the   upper  lip.     Instead   of   uniting 
Fig.  45i.  In  the  median  line,  a  fissure  exists 

which  may  include  either  the  soft 
structures  of  the  face  or  palate,  or  the  bones 
of  the  palate  as  well.  In  rare  instances  the 
cleavage  passes  up  into  the  eye  and  cranium 
(Figs.  4.j4,  455).  The  fissiiVe  is  usually  uni- 
lateral, and  may  be  so  small  that  it  is  scarcely 
noticed,  as  in  Fig.  456,  or  it  may  extend  half 
way  to  or  completely  into  the  nasal  cavity 
(Figs.  457,  458,  459).  One  side  of  the  lip  is 
much  thicker  than  the  other.  In  double  hare- 
lip the  fissures  are  about  the  same  distance 
from  the  median  line.  Both  may  extend 
into  the  nose,  or  one  (and  rarely  both)  may 
be  partial.     The  portion  intervening  may  be  Fig.  456. 


Fig.  457. 


Fig.  458. 


Fio.  459. 


THE  LIPS   AXD   CHEEKS. 


411 


composed  of  a  portion  of  the  lip  and  gum,  with  one  or  more  rudi- 
mentary teeth,  at  a  varying  angle  of  jirojection.  The  central  piece 
occasionally  is  attached  to  the  nose.  In  incomplete  single  hare-lip  the 
nostril  is  not  flattened  and  deformed,  as  is  the  case  when  the  fissure 
extends  through  the  pre-maxillary  bone  and  the  palate  and  alveolar 
processes  of  the  superior  maxilla 


(Fig.  460).     The  location  of  this 


fissure  is  most  frequently  between 


Fig.  400.— (After  Koenig.) 


Fig.  4i;1.— (After  Koenig.) 


the  first  and  second  incisor  teeth,  and  thi-ongh  the  inter-maxillary  bone, 
and  not,  as  frequently  given  by  some  writei's,  between  the  second  in- 
cisor and  canine  teeth,  extending  backward  through  the  pre-maxillary 
fjutnre. 

In  double  hare-lip  the  cleft  in  the  palate  is  usiially  double,  while  the 
center-piece  may  be  attached  to  the  vomer  (Fig.  461),  or  the  pre-maxil- 
lary portion  may  be  united  to  one  side  of  the  superior  maxilla  (Fig. 
460).  In  rare  instances  the  fissure  passes  obliquely  upward  and  out- 
ward, involving  the  eyelid,  orbit,  and  cranium,  producing  frightful  de- 
formity, as  shown  in  Fig.  455. 

Treatment. — The  only  relief  from  this  deformity  is  in  a  plastic  opera- 
tion. It  should  be  done  early,  and,  when  possible,  within  the  first  few 
months  of  life.  Hearty  and  well-nourished  infants,  with  simple  uni- 
lateral hare-lip,  should  be  operated  ujion  at  birth.  If  they  are  feeble,  an 
effort  at  forced  nutrition  should  be  made,  and  tlie  operation  x>osti)oned 
until  the  patient  is  brought  into  proper  condition.  Double  or  single 
hare-lip,  with  cleft  palate,  shovild  be  operated  upcm  early,  since  by 
drawing  the  lip  together  the  tension  on  the  suj)erior  maxillary  bones 
facilitates  closure  of  the  interosseous  cleft. 

The  methods  of  operating  are  numerous.  The  essential  features  of 
every  operation  are,  to  trim  the  edges  of  the  fissure  in  such  shape  that, 
when  they  are  approximated,  the  gap  will  be  closed  and  no  depression 
left  in  the  vermilion  border  of  the  lip. 

Single  Incomplete  Hare-Lip — First  Method. — Having  estimated  the 
extent  of  surface  required  to  fill  up  the  deficiency,  with  a  long,  sharp 


412 


A  TEXT-BOOK   ON   SURGERY. 


Fio.  402.— (After  Linhart.) 


knife  prick  the  integument  of  the  lip  at  a,  b,  c,  d,  and  e  (Fig.  462),  as 
guides  to  the  deep  incision.  Then  the  operator,  standing  in  the  position 
which  best  suits  his  convenience,  seizes  the  lip  between  his  thumb  and 

finger,    so  as   to   control    haDmorrhage,   and, 
i^^  while  the  opposite  side  is  held  by  an  assist- 

g"  M  V  ''^^^^'  transfixes  it  at  a,  cuts  from  a  to  c,  by 

smooth,  sliort  strokes  of  the  knife,  removes 
and  reinserts  the  blade  at  d,  and  cuts  into  the 
angle  at  c.     This  manoeuvre  is  repeated  in  the 
line  a,  b,  e.    With  a  strong,  blunt  pair  f)f  scis- 
sors the  soft  tissues  are  freely  lifted  from  the 
l)one,  until  the  edges  of  the  wound  can  be  ap- 
proximated without  any  degree  of  tension. 
If,  as  frequently  occurs,  one  side  is  so  much 
thicker  than  the  other  that  difficulty  is  expe- 
rienced in  keeping  the  approximated  edges  on  the  same  ])lane,  a  part  of 
the  under  surface  of  the  thicker  side  should  be  clipi)ed  oil  with  the  scis- 
sors.    Strong  silver  hare-lip  pins  (from  two  to 
four  in  number,  owing  to  the  length  of  the  in- 
cision) are  then  inserted,  being  made  to  enter  #  i^ 
about  one  fourth  of  an  inch  from  the  cut  edge, 
l)assing  through  the  entire  thickness  of  the  lip, 
and  out  at  a  corresponding  point  on  the  oppo- 
site side.     A  figure-of-8  silk  thread  is  wound 
about  these,  and  one  or  two  silk  sutures  are  in- 
serted, to  secure  a  jjerfect  approximation  at  all 
points.     The  pins  should  be  about  one  fourth  of 
an  inch  from  each  other,  and  the  lowest  should 

be  about  this  distance  from  the  vermilion  border.  The  last  suture 
should  pass  through  the  vermilion  border  (Fig.  463). 

In  adults  a  light  loose  dressing  of  sublimate  gauze  will  suffice  in  tlie 
after-treatment.  In  children  it  is  always  wise  to  siipport  the  sutures  by 
narrow  strips  of  adhesive  plaster,  carried  from  the  angle  of  the  jaw  across 
the  wound  to  the  opposite  side  of  the  face. 

The  pins  and  sutures  are  removed  between  the  third  and  fifth  days. 
No  rule  can  be  laid  down,  but  the  removal  should  be  made  as  soon  as 

union  has  taken  place.  For  the  few  days  im- 
mediately following  the  operation  the  muscles 
of  the  face  should  be  kept  as  quiet  as  possible. 
Silk  sutures  may  be  employed  if  the  pins  are 
not  at  hand.  "When  the  fissure  is  wider,  the  an- 
gles b  and  c  should  be  made  deeper,  as  shown  in 
Fig.  464.  When  approximation  is  completed, 
c  and  b  unite,  while  the  points  d  and  e  project 
below  the  level  of  the  normal  lip.  Any  re- 
dundancy of  tissue  or  overlapping  should  be 
allowed  to  remain  until  all  shrinkage  has  oc- 
curred, when  the  excess  may  be  trimmed  off  at  the  level  of  the  lip. 


Fig.  463.— lArtcr  Liiiliart.j 


Fio.  464. 


THE   LIPS  AND   CHEEKS. 


413 


Second  Method — Operation  of  Malgaigne. — With  a  sharp  bistoury 
pare  the  edges  of  the  fissure,  by  cutting  a  stri^D  on  each  side,  from  the 
apex  down  to  about  one  eighth  of  an  inch  from  the  free  border  of  the  lip. 


Fig.  4C5.— (After  Malgaigne.) 


Fir..  466. — (After  Miilgaigne.) 


The  strips  are  turned  down,  as  shown  in  Fig.  465,  and,  after  the  lip  on 
each  side  is  dissected  up  from  the  bone,  the  edges  are  approximated  and 
united,  as  shown  in  Fig.  466.  The  projecting  portion  is  treated  as  in  the 
X^receding  operation. 

Third  Method — Operation  of  Langenbeck. — Upon  one  side  of  the 
fissure,  as  at  b  (Fig.  467),  remove  a  naiTow  strip  from  the  apex  out  through 


Flu.  407.— (AUer  Liuhart,  Langenbeck.) 


Fig.  i')^. — (Alter  Linliart.) 


the  vermilion  border.  On  the  opposite  side,  a,  the  incision  extends  only 
to  within  one  eighth  to  one  fourth  of  an  inch  of  the  free  border.  After 
the  lip  is  freed  from  all  attachments,  the  edges  are  approximated  and 
fastened,  as  shown  in  Fig.  468. 

Fourth  Method — Operation  of  N'etaton. — Make  an  incision  parallel 


I'iG.  409. — (Alter  Nelutou,  Koeni^.) 


FiQ.  470.— (After  Koenig.) 


414 


A  TEXT-BOOK  ON  SURGERY. 


with  the  upper  half  of  the  fissure,  on  either  side,  the  incision  arching 
over  the  apex,  as  shown  in  Fig.  469,  a  h.  When  completed  and  turned 
down,  a  diamondsluiped  or  ellii)tical  opening  is  formed  (Fig.  470).  The 
pins  should  be  introduced  lioni  near  the  lateral  angles. 

Fifth  Method— Operation  of  Grae/e.—Make  a  horseshoe-shaped  in- 
cision along  the  apex  of  the  fissure,  as  at  a  (Fig.  471),  and  remove  tlie 


Fig.  4T1. — (.\l'tcr  Koenig,  Graefe.) 


Fig.  472. 


included  tissue  together  with  a  narrow  otrip  along  the  edge  of  the  fissure 
on  one  side,  as  at  b,  through  the  free  border  of  the  lip.  Upon  the  op- 
posite side,  and  near  the  middle  of  the  fissure,  an  incision  through  the 
thickness  of  the  lip  is  made  in  a  direction  outward  and  slightly  down- 
ward, as  at  c.  In  approximating  the  edges  (see  Fig.  472),  the  receding 
angle  at  a  is  united  to  b  on  the  opposite  side,  and  the  tip  of  the  free 
bordei",  d,  is  stitched  to  c. 

The  modification  of  this  procedure  by  Koenig  is  preferable  in  cases 
where  the  gap  has  unusual  width  at  the  vermilion  border.  The  horse- 
shoe incision  at  a  is  the  same  as  in  the  preceding  operation,  but  there 


Fig.  473.— (After  Ivoenig.) 


a 


Flo.  474.— (After  I^oenig.) 


are  two  lateral  horizontal  incisions,  S-3  (Fig.  473).  The  wound  has  the 
shape  shown  in  Fig.  474,  and  in  approximating  the  edges  the  apices 
of  the  two  flaps,  b  c  (Fig.  473),  are  brought  together  at  the  level  of  a 
(Fig.  474). 

Complete  Single  Hare-Lip — First  Method — Cozies' s  Operation. — In 
certain  cases  where  the  fissure  is  of  great  width,  and  extends  through  the 
floor  of  the  nose,  important  modifications  of  the  foregoing  procedures  are 
at  times  necessary.  The  operation  is  one  of  considerable  difficulty,  not 
only  as  to  the  closure  of  the  fissure,  but  on  account  of  the  flattening  of 
the  wing  of  the  nose  on  the  affected  side. 


THE   LIPS  AND   CHEEKS.  415 

In  the  milder  cases  the  procedure  of  Colles  may  be  undertaken.  Upon 
one  side  of  the  fissure  (usually  the  most  perpendicular  surface  is  selected) 
make  an  incision  parallel  with  and  about  one  eighth  of  an  inch  from  its 
free  border,  a  c  (Fig.  47.5).  Tliis  incision  terminates  short  of  the  wing  of 
the  nose  and  the  vermilion  border,  and  is  bisected  a  little  nearer  its  upper 
than  its  lower  end,  b.  The  opposite  surface  is  freshened  by  an  incision  in 
the  line  d  cf  (Fig.  475),  this  strip  being  entirely  removed.  When  the  soft 
parts  are  thoroughly  dissected  up,  the  edges  are  approximated,  so  that  the 
fiap  5  c  is  turned  down,  and  its  end  is  stitched  to  the  line  ef.  The  flap 
i  a  is  turned  up,  its  freshened  surface  being  stitched  to  the  upper  part  of 
the  line  e  d,  while  its  upper  edge  looks  into  the  cavity  of  the  nostrU. 


fio.  475.— (Alter  Linliart,  C'olks.)  Fio.  476.— (Jlodified  from  Koenij. ) 

Second  Method. — In  the  severer  forms  of  complete  unilateral  hare- 
lip, proceed  as  follows :  Freshen  the  edge  of  one  side  of  the  fissure  on 
the  line  indicated  by  b  a  (Fig.  476),  and  upon  the  opposite  side,  as  at  c  d, 
from  d  making  a  division  of  the  lip  outward  and  downward,  d  e,  in  the 
direction  of  the  corner  of  the  mouth,  and  as  far  as  may  be  necessary. 
Dissect  up  the  tissues  freely  from  the  bones,  and  make  a  horizontal  in- 
cision on  either  side,  as  shown  at  b  1,  c  1  (Fig.  476).  The  length  of  these 
incisions  wiU  depend  upon  the  degree  of  tension  required  to  bring  the 
flaps  into  apposition.  When  the  wing  of  the  nose  is  greatly  flattened 
the  defoi-mity  may  be  in  good  part  relieved  by  carrying  a  curved  incision, 
c^,  around  the  ala  nasi,  and  dissecting  loose  the  attachment  from  the 
maxillary  bone. 

Double  Hare-Lip. — The  method  of  operation  for  doiible  hare-lip  will 
depend  upon  the  size  and  position  of  the  middle  piece,  and  the  width 


Fig.  477.— (After  Koenig.)  Fig.  478.— (Alter  Koenlg.) 

and  depth  of  the  lateral  fissures.     If  the  central  piece  is  so  prominent 
that  it  will  exercise  too  great  tension  upon  the  lip  when  the  sutures  are 


410 


A  TEXT-BOOK   ON   SURGERY. 


inserted,  the  bony  projection  should  be  seized  with  a  strons:  forceps  and 
forced  back  into  a  safer  position,  or  broken  oil  with  a  chisel.  The  edges 
of  the  central  tip  must  be  trimmed  or  freshened.  The  lenuth  of  the  in- 
cision, a  b  (Fig.  477),  and  the  extent  of  the  dissection  of  the  lip  from  the 
jaw,  will  depend  upon  the  space  to  be  covered  in.  The  margin  from  a 
to  the  root  of  the  nose  is  not  freshened,  since  it  forms  the  floor  of  the 
nostril  when  the  operation  is  completed.  The  condition  of  the  parts 
when  ready  for  the  sutures  (pins  are  not  used  where  a  central  piece  is 
pi-eserved)  is  shown  in  Fig.  478.  The  points  h  h  meet  in  the  median  line 
of  the  lip,  while  a  a  are  sewed  to  the  central  piece. 

CheilopJadij— Upper  Lip.— In  addition  to  congenital  deficiency  of 
the  lips,  not  infrequently  as  a  result  of  accident  or  disease,  or  the  re- 
moval of  abnormal  growths  or  cicatrices,  the  surgeon  is  called  upon  to 
relieve  the  deformity  and  inconvenience  resulting  from  this  loss  of  tissue. 

In  the  upper  lip,  when  the  loss  of  substance  is  not  extensive,  as  in 
Fig.  479,  the  unsightly  appearance  may  be  remedied  by  making  two  in- 
cisions, curved  as  represented  by  the  lines  a  d,  a  d,  from  the  side  of  each 


,1 


Fig.  4T9. — (.Altur  Kosuv.) 


Fij.  4S0.— (Alter  Roscr.) 


ala  nasi  downward  and  inward  to  the  apex  of  tho  fissure.  The  soft  tis- 
sues should  be  dissected  up  and  brought  into  po.sition  by  sutures  applied 
as  in  Fig.  480.  If  after  the  dissection  the  tension  is  still  so  great  that  the 
parts  do  not  come  well  into  position,  a  horizontal  incision  should  be  made 
on  either  side,  beginning  near  the  root  of  the  nose,  and  carried  directly 

outward,  or  slightly  outward, 
and  downward,  as  the  shape  of 
the  flap  may  require.  AVhere 
there  is  greater  loss  of  sub- 
stance, Burrows's  method  is 
advisable  (Fig.  481).  Make  a 
horizontal  incision  on  each  side, 
commencing  in  the  angle  of 
the  mouth,  and  going  entirely 
through  the  lip,  a  b,  c  d,  and 
unite  these  at  Ic  and  J.  Dis- 
sect out  the  triangular  piece 
J  a  b,  7c  c  d.  Make  now  two 
other  horizontal  incisions,  which 
run  into  the  nasal  cavity  g  Ti 
and  /  f ,  and  dissect  out  two  smaller  triangles,  /  e  m  and  g  h  I.  The 
proximal  edges  of  the  quadrilateral  flaps  gJicd  and  efab  should  now 


Fiu.  481.— (After  Linhart.) 


THE  LIPS  AND  CHEEKS. 


411 


be  freshened  and  freely  lifted  by  dissection,  and  the  sutures  intro- 
duced. It  will  be  obsei-ved  that  as  the  edges  are  approximated,  the 
lines  d7i\  b  j\  mf,  and  7  7^  will  be  united  with  c  A",  aj,  me,  and  If/. 

A  third  method,  which  is  useful  in 
certain  cases,  is  as  follows :  After  the 
disease  is  removed,  an  incision,  c  a 
(Fig.  482),  is  carried  from  the  ala?  of 
the  nose  iipward  and  outward.  The 
length  of  this  cut  and  its  obliquity  de- 
jiend  upon  the  distance  to  be  tilled  be- 
tween the  normal  line  of  the  lip  and 
the  nose.  A  second  incision,  a  b,  is 
now  carried  deeply  downward  and  out- 
wai'd,  making  a  quadrilateral  flap, 
which  hinges  at  b  d,  and  is  dissected 
up,  and  the  edges,  c  «,  are  brought  in 
apposition  and  secured  in  the  median 
line. 

Lower  Lip. — When  the  loss  of  tissue  has  left  a  cavity  triangular  in 
shape,  as  in  Fig.  483,  that  one  of  the  following  methods  may  be  selected 
which  in  the  judgment  of  the  opera- 
tor is  best  adapted  to  the  case  : 


Fig.  482.— (After  Linhart.) 


Fig.  4S4.— (After  Linhart.) 


Both  flaps  are  now  loosened  and 

Along  the 


Fig.  433. — (After  Szymanowsky.) 


1.  A  horizontal  cut,  a  b  (Fig.  484), 
is  made  outwartl  from  the  angle  of 
the  lip,  and  a  second  one,  b  c,  parallel 
Avith  the  freshened  edge  of  the  Assure. 

slid  toward  the  median  line,  and  united  by  pins  or  sutures 
free  border  of  the  new  lip  stitch  the  mu- 
cous membrane  to  the  skin  with  fine  silk 
sutui'es.    The  gap  left  on  either  side  is  also 
wholly  or  partially  closed  by  sutures. 

2.  For  the  same  defect  make  a  semi- 
circular incision  outward  and  downward 
from  each  ingle  of  the  mouth,  c  g  d  and 
afe  (Fig.  485).  Dissect  this  flap  up  freely 
and  slide  toward  the  middle  line.  The  pin- 
sutures  are  inserted  as  in  Fig.  480,  taking 

27 


Fio.  4S5. — (.VftcT  Szyraanowsky.) 


418 


A   TEXT-BOOK   ON  SURGERY. 


r  \  Hie  precaution  to  sew  the  nuicons  membrane 

^~^»"^_--ev/  /      to  the  integument  along  the  edge  of  the 

newly  made  lip. 

3.  If  the  lis.siire  is  less  extensive,  make  a 
horizontal  incision  from  each  angle  of  the 
mouth  through  the  entire  thickness  of  the 
lip  for  a  sulhcient  distance  (,Fig.  487),  a  e, 
e  d^  dissect  up  the  triangular  Haps,  and  ad- 
just Avitli  i)in-suture.s,  as  shown  in  Fig.  488. 
When  the  apex  of  the  triangular  defect  does  not  di])  down  too  far 
the  teeth,  the  unilateral  sliding  operation  of  Blasius  nuiy  be  pi-ac- 


FiG.  486.— (Aftur  S/yiiianowsk.v.) 


4. 
from 


Fio.  487.— (Alter  Szymanowsky.) 


Fio.  488. — (Alter  Szvmanow.iky.) 


ticed.  Fi'om  the  apex  of  the  angle,  c  (Fig.  489),  make  a  deep  cut,  ced, 
downward  and  outward  over  the  side  of  the  chin,  in  the  main  a  continu- 
ation of  the  line  of  the  defect,  bfc. 
The  flap,  aced^  is  dissected  up  and 
slid  so  that  c  is  attached  to  h  (Fig.  490). 
5.  When  the  defect  extends  in  the 
shape  of  an  isosceles  triangle  with  the 
apex  low  down  upon  the  chin,  the 
method  of  Burrows  (Fig.   491)  is  ap- 


Fio.  48S).— (Aller  Szymanowsky.) 


Flo.  490. — (After  Szymaiiowsky.) 


Fio.  491.— (After  Linhart.) 


plicable.     Two  triangular  pieces,  nfJi,  hgk,  are  removed  from  the  tis- 
sues just  above  the  angles  of  the  mouth.     The  edges  of  the  fissure  are 


THE  LIPS  AND   CHEEKS. 


419 


freshened,  the  flaps,  fadgbd,  dissected  loose,  and  the  lines,  a e,  he, 
approximated  by  sutures. 

0.  When  the  defect  is  long  and  rectangular,  as  shown  in  Fig.  492,  the 
procedure  of  Von  Bruns  may  be  successfully  employed.  The  diseased 
tissue  being  removed,  the  quadrilateral  flaps,  abed  (Fig.  493),  are  dis- 


Fio.  492.— (After  LiiiLart.) 


Fig.  493.— (After  Linhart.) 


sected  out  and  brought  down,  uniting  ohm  the  median  line  and  ab  on 
either  side  to  the  line  a  a.  The  defect  left  on  both  sides  of  the  outer 
aspect  of  the  upper  lip  may  be  wholly  or  in  great  part  closed  by  sutures. 
The  outer  incision  should  not  be  carried  far  enough  back  to  wound  the 
duct  of  Steno. 

7.  Or  the  flaps  may  be  turned  from  below,  as  advised  by  Sedillot 
(Fig.  494).  The  inferior  oblique  lines  are  carried  to  the  middle  line  and 
stitched  to  each  other.     The  defect  is  closed  by  sutures  (Fig.  495). 


Fio.  494.— (.Vtler  Malgaigne.) 


Fig.  495. — (After  Malgaignc.) 


Cheeks. — When  the  loss  of  substance  is  not  extensive,  the  edges  may 
be  dissected  up  to  a  limited  extent,  pared,  and  brought  directly  together 
by  sutures.     If  this  can  not  be  accomplished,  incisions  shaped  as  shown 


4l>0 


A  TEXT-BOOK   ON   SURGERY. 


in  Fig.  4'JG  (Mutter's  method),  ab,  ae,  may  be  made,  the  Haps  lifted,  and 
brought  together  by  sutures.  The  gaps  left  above  and  below  may  be 
also  closed  at  once. 

Sliding  a  flap  from  the  neck  is  sliovvn  in  Fig.  497,  where  the  llaj), 
b  a  d,  is  brought  up  to  till  the  oval  s\ydce  left  by  removal  of  the  diseased 


Fia.  490.— (After  Roser.) 


Fio.  4'j7. — (After  Ma)gaigne.) 


tissue,  b  ca.  The  pedicle  is  divided  as  soon  as  union  has  occurred,  and 
the  stump  returned,  as  in  r7n')/oplast>/. 

In  contrarlion  of  the  mouth  the  orifice  may  be  enlarged  by  incising 
the  angles  in  a  horizontal  direction,  finishing  the  operation  by  stitching 
the  skin  and  mucous  membrane  together.  Or  an  elastic  ligature  may  be 
introduced  through  the  cheek  at  the  required  distance  from  the  angle, 
brought  out  at  the  corner  of  the  mouth,  and  tied.  During  the  slow  pro- 
cess of  cutting  through,  the  track  of  the  wound  becomes  covered  with 
epithelia,  and  reunion  is  prevented. 

In  the  selection  of  any  of  the  plastic  methods  heretofore  given,  the 
surgeon  must  be  guided  by  the  requirements  of  each  case.  It  is  a  wise 
precaution  to  make  a  guarded  prognosis,  for,  no  matter  how  .successful 
from  the  surgical  standpoint,  the  operations  do  not,  in  the  majority  of 
instances,  secure  the  expected  improvement  in  the  personal  appearance 
of  the  patient. 


Parotid  Gland  and  Duct. 

Salivary  fistula  may  be  confined  to  the  main  parotid  duct  in  any  part 
of  its  course,  or  to  the  primary  ducts  within  the  substance  of  the  gland. 

It  may  result  from  a  wound  or  any  inflammatf)ry  and  necrotic  process 
due  to  obstruction  from  salivary  calculi  or  other  disease  of  the  x'iU'otid 
and  buccal  regions.  Exploration  of  the  duct  with  a  delicate  blunt  probe 
is  accomplished  thus :  Find  the  outlet  at  the  papilla  on  the  mucous 
membrane  of  the  buccal  cavity  near  the  junction  of  the  second  bicuspid 


PAROTID   GLAND   AND   DUCT.  421 

and  first  molar  teeth  of  tlie  upper  jaw.  Introduce  the  probe,  carrying  it 
at  first  slightly  outward.  When  it  is  arrested  by  the  natural  curve  of  the 
duct,  pull  tlie  corner  of  the  mouth  and  the  cheek  directly  outward,  thus 
straightening  the  tube.  The  general  direction  is  backward,  toward  the 
auditory  meatus. 

The  diagnosis  of  salivary  fistula  or  of  obstructed  duct  may  be  deter- 
mined as  follows :  By  means  of  absorbent  cotton  or  lint  remove  all 
moisture  from  the  mucous  surface  where  the  papilla  is  situated,  and  place 
some  sapid  or  acid  substance  on  the  tongue.  If  there  is  no  obstruction, 
the  flow  of  saliva  is  immediately  perceived.  In  case  of  fistula  the  secre- 
tion will  flow  out  through  it.  Calculi  of  Steno's  duct,  or  of  any  of  the 
salivary  ducts,  should  be  removed  by  dilatation,  if  this  is  possible,  and 
if  not,  by  incision. 

In  the  treatment  of  salivary  fistula  the  object  aimed  at  is  to  stop  the 
flow  of  saliva  on  the  outside  and  turn  it  into  the  mouth.  Arm  a  probe 
with  a  silk  seton  and  carry  it  through  the  fistula  into  the  buccal  cavity, 
bring  the  thread  out  through  the  mouth,  and  tie  the  two  ends  together. 
In  about  ten  days  the  flow  into  the  mouth  will  be  fully  established, 
when  the  seton  should  be  removed  and  the  outer  opening  closed  by  a 
compress  imtil  cicatrization  occurs.  It  may,  at  times,  be  necessary  to 
freshen  the  edges  and  bring  them  together  with  a  suture. 

Riberi  operated  successfully  by  cutting  through  the  integument 
down  ujjon  the  duct  behind  the  opening,  passing  a  ligature  around  it, 
and  carrying  this  and  the  end  of  the  duct  into  the  buccal  cavity  where 
it  was  left  open.  The  wound  in  the  integument  was  immediately  su- 
tured. 

Fistula  of  the  primary  ducts  within  the  substance  of  the  gland  may 
require  the  forced  atrojihy  or  ablation  of  this  organ.  An  effort  at  oc- 
clusion should  be  made  by  direct  pressure  uj^on  the  abnormal  opening. 

Tumors  of  tlie  Parotid. — About  30  per  cent  of  all  neoplasms  of  this 
organ  are  enchondroraata,  25  carcinomata,  while  the  remaining  45  per 
cent  are  about  equally  divided  between  sarcomata,  fibromata,  myxomata, 
and  cystomata.  Simple  hypertrophy  is  rare,  although  hyi)erplasia  of 
the  gland-tissue  occurs  in  a  varying  degree  in  the  progress  of  most  of 
the  neoplasms  which  attack  this  organ. 

Tumor  of  the  parotid  is  rare  prior  to  the  thirtieth  year  of  life,  being 
met  with  chiefiy  between  the  thirtieth  and  fiftieth  years.  As  to  the 
period  when  the  various  forms  appear,  it  maj'  be  said  that  carcinoma 
occurs  generally  after  the  fiftieth  year,  while  enchondroma,  sarcoma, 
myxoma,  and  fibroma  develop  in  the  earlier  decades.  Sarcoma  is  apt  to 
develop  in  cliildhood  or  early  adult  life. 

Diagnosis. — All  forms  of  tumor  of  the  parotid,  as  a  rule,  develop 
slowly.  In  the  earlier  stages  of  their  development  they  are  movable 
within  the  limited  area  of  mobility  of  the  gland.  This  is  true  of  both 
the  benign  and  malignant  growths.  Later,  even  the  benign  neoplasms 
may  become  fastened  between  the  temporal  bone  and  fascia  and  the 
ramus  of  the  jaw,  but  not  to  the  overlying  integument.  The  malignant 
growths  are  more  rapid  in  development,  and  earlier  in  their  history  are 


422  A  TEXT-BOOK   ON   SURGERY. 

bound  down  to  the  sniTounding  tissncs,  may  become  adherent  to  the 
integument,  and  produce  great  pain  and  disturbance  by  reason  of  press- 
ure u]ion  the  nerves  and  vessels  witli  whicli  the  gland  is  in  close  relation. 

The  cartilage  tumors  are  nodular,  hard,  and  slightly  elastic  to  direct 
pressure.  Cancer  is  also  nodular  at  times,  but  not  so  hard  as  enchon- 
droma.  Cancer  comes,  as  a  rule,  after  the  forty-lifth  to  liftieth  year, 
and  the  other  neoplasms  before  this  period.  The  lymphatic  glands  are 
involved  in  cancel',  and  rarely  enlarged  in  any  other  fomi  of  neoplasm. 
Sarcoma  occurs  earliest  of  all.  Cysts  are  elastic,  may  present  fluctua- 
tion, while  the  exact  character  of  this  variety  may  be  determined  by 
exploration  with  the  aspirator.  If  of  great  importance  in  determining 
the  plan  of  treatment  to  be  pursued,  a  section  of  the  diseased  organ 
suificiently  large  for  microscopic  examination  sliould  be  removed  ;  in 
this  way  a  positive  diagnosis  is  assured. 

Removal  of  the  parotid  gland  is  one  of  the  most  difficult  operations 
in  surgeiy.  In  many  cases  of  tumor  of  this  organ  in  which  the  neo- 
plasm is  developed  at  the  expense  of  the  under  portion  of  the  gland, 
the  internal  jugular  vein,  internal  carotid  artery,  and  the  important 
nerves  and  ganglia  situated  here  become  so  involved  that  complete  ex- 
tirpation is  impossible  during  life.  This  condition  was  found  to  exist  in 
a  case  in  which  I  removed  all  of  the  organ  anterior  to  the  deep  vessels. 
Having  at  first  tied  the  external  carotid  artery,  the  dissection  was  com- 
paratively bloodless.  When  the  tumor  is  of  small  size,  it  may  be  en- 
tii'ely  removed.  Section  of  the  various  divisions  of  the  facial  nerve  or 
of  the  main  trunk  is  almost  inevitable.  If  the  external  carotid  is  first 
secured  it  may  be  avoided  by  a  careful  dissection,  provided  that  the 
tumor  is  of  moderate  size. 

Operation. — Make  a  crucial  incision  over  the  mass,  the  perpendicular 
cut  being  in  the  line  of  the  external  carotid  artery.  Turn  the  flaps 
back  from  the  anterior  aspect  of  the  tumor,  and  approach  its  deeper 
portions  from  below  in  the  line  of  the  vessels.  As  soon  as  the  external 
carotid  can  be  exposed,  it  should  be  secured  with  a  catgut  ligature.  All 
bleeding  should  be  arrested  as  the  operation  proceeds.  In  lifting  the 
under  surface  of  the  tumor  from  its  bed,  the  operator  should  keep  close 
to  the  mass,  using  a  dull  instrument  for  fear  of  wounding  the  internal 
jugular  vein  and  other  important  vessels  or  nerves.  The  blunt  scissors 
curved  on  the  flat,  the  handle  of  the  scalfjel,  or  the  thumb  and  finger- 
nail may  be  utilized  for  this  j^urpose.  The  facial  nerve  and  its  branches 
which  run  through  the  neoplasm  should  be  saved,  if  possible.  As  before 
stated,  if  the  tumor  is  extensive,  this  is  scarcely  possible  on  account  of 
the  great  length  of  time  it  woiild  require.  If,  in  the  course  of  the  opera- 
tion, it  is  discovered  that  the  neoplasm  dips  down  beneath  the  jaw  and 
styloid  process,  and  surrounds  the  vessels  and  nei*ves,  its  complete  ex- 
tirpation is  impossible.  As  much  of  the  mass  as  can  be  lifted  should 
now  be  transfixed  near  the  middle  with  a  double  elastic  ligature,  tied, 
and  the  part  external  to  the  ligature  cut  away. 

The  2^1'ognosis  in  cancer  and  sarcoma  of  the  parotid  is  always  grave, 
even  after  removal.      The  anatomical  relations  of  this  organ  are  such 


PAROTITIS.— SUBMAXILLARY  GLAND.— THE  JAWS.         423 

that  a  wide  and  complete  extirpation,  sacli  as  is  readily  made  in  tumors 
of  the  breast,  is  impossible.  The  question  will  naturally  arise,  Under 
what  conditions  should  the  operation  be  advised  and  undertaken  ?  In 
malignant  disease  the  propriety  of  extirpation  is  very  questionable,  and 
should  only  be  undertaken  after  a  clear  explanation  of  the  dangers  of 
the  operation  and  the  probabilities  of  recurrence.  In  benign  tumors 
which  show  a  tendency  to  increase,  operation  may  be  advised,  especially 
if  the  tumor  is  still  of  small  size.  It  is  always  important  to  attempt  the 
removal  of  the  neoplasm  early  in  its  history.  Facial  paralysis  generally 
follows  the  oijeration,  and  is  more  or  less  permanent. 


Parotitis — "  Mumps." 

Inflammation  of  the  parotid  gland  occurs  chiefly  in  children,  but  is 
occasionally  met  with  in  adults.  In  males  it  is,  at  times,  accompanied 
by  orchitis,  and  in  females  the  mammary  glands  and  ovaries  are  aifected. 
The  symi^toms  are  pain  and  swelling  of  the  gland,  difficult  deglutition, 
and  slight  febrile  movement.  The  prognosis  is  favorable,  the  disease 
yielding  to  warm  applications,  quiet,  and  the  judicious  employment  of 
laxatives.  In  rare  instances  atrophy  of  the  testicle  has  been  known  to 
follow  the  inflammation  of  this  organ,  occurring  as  a  complication  of 
"m?/7?i^5." 

Abscess  may  occur  after  an  acute  inflammation  of  the  parotid  from 
traumatism,  or  as  a  complication  of  the  eruj)tive  or  continued  fevers. 
Under  these  last  conditions  the  prognosis  is  always  grave.  The  presence 
of  pus  is  recognized  by  the  intense  character  of  the  pain  experienced, 
the  febrile  movement,  the  doughy  condition  of  the  skin  and  areolar 
tissue  in  front  of  the  organ,  and  by  aspiration.  The  abscess  should  be 
evacuated  by  aspiration,  puncture,  or  incision. 


Submaxillary  Gland. 

This  organ  may  become  inflamed  and  suppurate,  or  be  the  seat  of 
neoplasms,  yet  not  so  frequently  brought  to  the  attention  of  the  sur- 
.geon  as  the  parotid.  Its  removal  is  a  simple  procedure,  and  may  be 
accomplished  by  a  crescentlc  incision  commencing  at  the  angle  of  the 
Jaw,  dipping  three  quarters  of  an  inch  toward  the  hyoid  bone,  and  end- 
ing one  and  a  half  inches  in  front  of  the  angle  at  the  lower  border  of  the 
jaw.  The  flap  of  skin  should  be  raised  with  the  platysma  muscle  as  far 
as  the  jaw,  and  the  deep  cervical  fascia  divided.  The  gland  rests  be- 
neath and  internal  to  the  bone  and  upon  the  mylohyoid  and  hyoglossiis 
muscles.     The  submaxillary  branch  of  the  facial  artery  will  be  divided. 

The  Jaws. 

Sitpen'o)'  3IaxiUa. — Periostitis,  ostitis,  and  abscess  of  the  upper  jaw 
may  be  caused  by  caries  of  the  teeth,  disease  of  the  upper  jaw  within 


424  A  TEXT-BOOK   ON   SURGERY. 

the  antrum,  or  patliological  changes  within  the  bone  proper.  Ostitis  of 
the  niaxilhi  is  more  apt  to  occiii'  in  chiklren,  and  especially  in  those  of  a 
strumous  diathesis.  Ph()s]ihorus-i)()is()ning  and  the  syi^hilitic  dyscrasia 
lead  also  to  intiamniation  and  caries  of  tliis  l)one. 

The  symptoms  of  ostitis  and  abscess  here  do  not  differ  from  those 
already  given  in  the  general  cliajiter  on  bone  diseases.  Pain  is,  ]ierhaps, 
more  acute  in  ostitis  wit liiu  the  distribution  of  the  trifacial  nerve.  It  iiJ 
elicited  by  direct  pressure,  and,  when  the  process  is  associated  with  a 
carious  tooth  or  its  roots,  the  exact  location  may  be  determined  by 
striking  the  tooth  sharply  with  a  metallic  substance. 

The  treatment  is  to  relieve  the  tension  by  puncture  or  incision,  or 
by  extraction  of  one  or  more  teeth  in  case  they  are  connected  with  the 
diseased  surface.  The  removal  of  dead  bone  is  demanded,  although  it  is 
wise  not  to  operate  too  early.  When  exfoliation  has  occurred,  the  oper- 
ation is  much  simplified.  If  free  drainage  is  secured  by  early  incision, 
the  arrest  of  the  spread  of  the  disease  is  practically  insured.  Chronic 
alceolar  abscess  is  often  cured  by  extraction  of  an  offending  tooth. 
When  this  fails,  the  diseased  surface  should  be  exposed  by  incision,  and 
a  thorough  removal  accomplished.  When  possible,  all  sequestra  should 
be  removed  from  within  the  oval  cavity  in  order  to  avoid  a  scar  iqion  the 
face. 

Syphilitic  ostitis,  and  that  variety  which  occurs  from  absorption  of 
the  fumes  of  phosphorus,  require  specific  constitutional  treatment  as 
well  as  operative  interference. 

Abscess  of  the  antrum  of  Highmore  may  occur  as  the  result  of  an 
infiammatory  process  in  the  mucous  membrane  lining  this  cavity,  or  in 
connection  with  ostitis  of  the  upper  jaw,  or  from  the  presence  of  foreign 
bodies  or  neoplasms  within  its  cavity.  The  chief  symptom  is  pain,  re- 
ferred to  the  region  of  the  antrum.  The  febrile  movement  of  acute  ab- 
scess is  usually  present.  The  pus  may  force  its  way  through  the  open- 
ing into  the  meatus,  or  cause  necrosis  in  the  bone  and  discharge  in  any 
direction. 

Treatment. — I^ree  drainage  must  be  established  in  all  cases.  The 
extraction  of  the  first  or  second  molar  and  the  application  of  a  drill  to 
enlarge  the  opening  may  suffice.  If  necessary,  a  portion  of  the  alveolar 
process  should  be  gnawed  away  with  the  forceps.  In  extreme  cases  an 
incision  should  be  made  through  the  skin  just  above  the  situation  of  the 
first  molar  tooth,  and  a  thorough  opening  made  with  a  trephine  or 
gouge.  It  is  important  to  explore  the  cavity  with  the  finger  in  order  to 
determine  the  presence  of  dead  bone  or  any  offending  substance.  Free 
drainage  must  be  maintained  uutil  recovery  is  secured.  In  a  case  which 
came  under  my  observation,  I  found  the  cause  of  an  abscess  of  thirteen 
years'  duration  to  be  a  supernumerary  molar  tooth  which  was  lying 
loose  in  the  antrum. 

The  same  operation  will  be  most  essential  in  those  cases  of  hydrops 
antri,  or  retention  of  fluid,  and  in  the  cure  of  cysts  of  this  cavity. 

Among  the  many  other  diseases  to  which  the  antrum  is  subject  are 
myxoma,  fibroma,  pax^illoma,  sarcoma,  carcinoma,  and  various  hyperos- 


THE  JAWS.  425 

toses.  The  differentiation  of  these  growths  is  extremely  difficult,  and, 
when  doxibt  exists  as  to  the  character  of  the  neoplasm,  an  exploi'atory 
operation  for  the  puri:)ose  of  positive  diagnosis  should  be  made.  This 
is  done  by  aj^plying  the  trephine  as  just  given. 

Non-malignant  new  formations  may  be  removed  by  an  osteoi^lastic 
operation,  while  malignant  growths  often  require  the  sacrifice  of  the 
entire  upper  jaw. 

Osteoplastic  Operation  for  Removal  of  Benign  Tumor  from  the  An- 
trum of  Ilighmore — Langeiibec7c\'^  Procedure. — From  the  junctif)n  of 
the  wing  of  the  nose  with  the  lip  an  incision  is  carried  outward  parallel 
with  the  level  of  the  teeth,  and  is  made  to  divide  the  soft  parts  to  the 
bone  as  far  as  the  center  of  the  malar  prominence,  where  it  is  curved  up- 
ward and  inward,  ending  a  quarter  of  an  inch  below  the  outer  angle  of 
the  orbit.  This  is  joined  by  a  second  incision,  which  is  commenced  about 
a  quarter  of  an  inch  below  the  level  of  the  orbit  at  the  suture  between 
the  nasal  bone  and  the  nasal  process  of  the  superior  maxilla,  and  is  car- 
ried outward  parallel  with  the  lower  margin  of  the  orbital  cavity. 

The  tissues  must  not  be  lifted  from  the  periosteum  within  this  curved 
incision.  The  hjemorrhage,  which  is  always  sharp,  being  arrested,  with 
a  blunt  instrument  carefully  lift  the  eye  from  the  floor  of  the  orbital 
cavity  until  the  finger  can  be  carried  into  the  anterior  portion  of  the 
spheno-maxillary  fissure.  With  this  as  a  guide,  insert  a  small,  strong 
key-hole  saw  into  the  fissure  and  divide  the  ma- 
lar bone  outward  in  the  line  of  the  incision  (see 
Fig.  498).  In  moving  the  saw,  keep  the  blade 
perpendicular,  and  limit  the  motion  so  that  the 
point  may  not  penetrate  the  temporal  fossa  and 
wound  the  vessels.  Next  insert  the  saw  in  the 
lower  horizontal  incision  and  divide  the  supe- 
rior maxilla  into  the  cavity  of  the  antrum  and 
nose.     In  sawing  on  this  line,  keep  the  mouth  Fig.  4y8. 

open  and  the  finger  inserted  behind  the  j^Jilate  to 

prevent  the  point  of  the  instrument  from  penetrating  too  far  back.  The 
nasal  process  of  the  superior  maxilla  is  now  divided  with  a  chisel  at  a 
point  half  way  between  the  inferior  orbital  foramen  and  the  inner  angle 
of  the  orbit.  The  cutting-edge  of  the  chisel  shoiild  be  directed  slightly 
outward  for  fear  of  injuring  the  lachryino-nasal  duct.  The  lines  of  sec- 
tion in  the  bones  are  shown  in  Fig.  498.  The  jjoint  of  exit  of  the  infra- 
orbital nerve  should  be  found  and  this  branch  of  the  trifacial  divided  at 
the  foramen.  An  elevator  is  now  placed  in  the  fissure  made  by  the  saw 
through  the  malar  bone  and  the  mass  dislocated  inward,  hinging  on  the 
undivided  soft  tissues.  This  force  fractures  the  floor  of  the  orbit  and 
opens  widely  the  antrum  of  Ilighmore.  When  the  operation  is  finished, 
the  bone  is  neatly  replaced  and  the  edges  of  the  wound  accurately  ad- 
justed. Drainage  may  be  secured  through  the  wound,  or  a  hole  may  be 
drilled  through  the  edge  of  the  alveolus.  This  same  operation  is  advis- 
able in  section  of  the  second  l)ran('h  of  tlie  fifth  nerve  and  extirjiation  of 
Meckel's  ganglion.     When  the  ganglion  is  the  objective  point,  it  may  be 


426 


A  TEXT-BOOK   ON   SURGERY. 


fownd  by  following  the  superior  maxilhuy  branch  of  the  fifth  nerve  nlong 
the  floor  of  the  orbit  to  the  location  of  the  ganglion  on  the  anterior  sur- 
face of  the  pterygoid  process  of  the  sijhenoid  bone.  The  posterior  shell 
of  the  antrum  must  be  broken  through  in  order  to  enter  the  fossa. 


Operatiox  fou  Ke.moval  of  the  Upper  Jaw. 

A  quarter  of  an  inch  below  the  inner  canthus  of  the  eye  commence  an 
Incision  and  carry  it  downward  along  the  naso-maxillary  groove,  curving 
in  the  contour  of  the  ala  nasi,  then  horizontally  beneath  the  ala  to  the 
median  line  of  the  lip,  where  it  tui'ns  directly  downward,  dividing  the 
lip  in  the  median  fissure.  From  the  point  of  beginning  carry  a  second 
incision  one  fourth  of  an  inch  below  and  parallel  with  the  inferior  mar- 
gin of  the  orbit  out  to  the  prominence  of  the 
malar  bone  (Fig.  499).  Dissect  up  the  soft  tis- 
sues of  the  cheek,  and  turn  the  flap  downward 
and  outward.  If  the  disease  is  so  extensive 
that  the  incision  does  not  expose  the  parts 
^,^  _-,      J         sufl[iciently,  a  horizontal  cut  may  be  made  out- 

''^■^^  >     ^.         ward  from  the  angle  of  the  mouth. 

^^t'.  ^^,  The  bone  may  be  divided  by  the  saw  insert- 

ed in  the  spheno-maxillary  fissvire,  as  in  the 
preceding  operation,  cutting  through  the  nasal 
process  with  a  chi-sel.  Extract  an  incisor  tooth, 
and  with  large,  strong  bone-cutting  forcejis  di- 
vide the  alveolus  and  the  palate-process  by  in- 
serting one  blade  in  the  nose  and  the  other  in 
the  mouth.  These  sections  being  accomi)lished, 
avulsion  is  made  by  means  of  elevator  and  for- 
ceps. The  operation  is  completed  by  the  clos- 
ure of  the  wounds  with  fine  silk  sutures.  If,  in  section  of  the  palate, 
the  Paquelin  cautery  is  used,  hsemorrhage  will  be  less  annoying.  Rec- 
tal ansesthesia  is  preferable  in  these  major  operations  about  the  mouth. 

Preliminary  tracheotomy  and  plugging  the  pharynx  and  larynx  with 
sponges  in  order  to  prevent  haemorrhage  into  the  trachea  is  rarely,  if 
ever,  required.  If  such  precaution  is  considered  necessary,  an  ordinary 
trachea- tube  will  suffice.* 

Neurectomy. — Exsection  of  a  portion  of  the  second  division  of  the 
fifth  nerve  may  be  made  at  three  jioints — at  its  exit  from  the  infra-orbital 
canal,  within  the  canal,  or  at  the  foramen  rotundum.  In  this  last  opera- 
tion the  spheno-m«xillary  ganglion  is  also  extirpated.  If  the  cause  of 
the  neuralgia  is  peripheral,  make  an  incision  aboiit  one  inch  long,  par- 
allel with  and  half  an  inch  below  the  lower  margin  of  the  orbital  cavity. 

*  Trendelenburg's  tnichca-tube  and  tampon  is  such  a  complicated  apparatus  that,  when 
possible,  it  should  he  dispensed  with.  It  is  more  to  be  commended  in  laryngectomy  than  in 
any  other  operation  about  the  mouth  or  pharynx.  The  mechanism  of  this  tube,  and  the 
method  of  using  it,  are  given  on  page  457. 


Fio.  499.— (After  Eoser.i 


THE  LOWER  JAW.  427 

The  center  of  this  cut  should  be  over  the  infra-orbital  foramen,  which 
is  just  half  way  between  the  outer  and  inner  angle  of  the  orbit.  The 
nerve  may  be  exsected  here  or  stretched  by  pulling  on  the  central  end. 
It  may  be  reached  at  a  iioint  considerably  behind  this  by  trepliining  tlie 
antrum.  Make  a  curved  incision,  beginning  about  half  an  inch  below 
the  inner  canthus,  passing  downward  to  the  level  of  the  end  of  the  nose, 
thence  ux)ward  to  a  point  about  half  an  inch  below  the  outer  canthus. 
Dissect  this  flap  upward,  apply  the  trephine  so  that  its  upper  edge  will 
cut  just  below  the  foramen  and  enter  the  antrum.  The  nerve  runs  di- 
rectly backward,  and  may  be  followed  by  keeping  it  as  a  guide  and 
breaking  off  the  lower  shell  of  the  canal  as  far  back  as  the  posterior  wall 
of  the  antrum,  where  it  is  divided. 

The  operation  for  the  removal  of  Meckel's  ganglion  has  already  been 
given. 

The  Lower  Jaw. 

Ostitis  of  the  inferior  maxilla  is  of  frequent  occurrence. 

Various  forms  of  fibroma,  fibro-myxoma,  encysted  fibroma,  enchon- 
droma,  and,  in  rare  instances,  angioma,  have  been  observed  in  this  bone, 
but  of  new  formations  sarcoma  is  most  frequent.  Cystic  formations 
resulting  from  failure  of  normal  development  of  the  teeth  are  not  un- 
common. 

Ostitis  occurs  most  frequently  in  children.  It  may  be  an  expression 
of  a  dyscrasia,  or  an  accident  of  nutrition,  or  be  secondary  to  disease  of 
the  teeth,  or  the  inhalation  of  the  fumes  of  phosphorus.  While  this 
process  may  be  located  at  any  portion  of  the  jaw,  the  neighborhood  of 
the  angle  seems  to  be  most  frequentlj^  affected. 

The  symptoms  are  pain,  followed  by  sweUing  of  the  jaw  and  contigu- 
ous soft  tissues,  ending  in  abscess,  which,  if  left  alone,  eventually  opens 
and  discharges. 

Treatment. — As  soon  as  the  character  of  the  disease  is  evident,  an 
incision  or  puncture  should  be  made  through  the  overlying  tissues  and 
periosteum,  in  order  to  give  free  exit  to  pus  and  loose  particles  of  bone. 
The  operation  for  removal  of  the  dead  bone  may  be  delayed  for  several 
weeks  until  exfoliation  has  taken  place.  Incision  should  always  be  made 
below  the  line  of  the  jaw  if  this  is  feasible,  so  that  the  resulting  scar 
will  be  less  ajiparent.  Usually  by  following  the  track  of  the  abscess  it 
will  lead  directly  to  the  dead  bone  surrounded  by  an  involucncm.  This 
often  requires  to  be  chiseled  or  forced  open  to  allow  the  extraction  of 
the  sequestrum,  which  may  be  readily  removed  with  ordinary  bone-  or 
dressing-forceps.  The  cavity  should  be  well  scraped  with  a  Volkmann's 
spoon,  a  drainage-tube  left  in,  and  the  edges  of  the  wound  adjusted  with 
silk  sutures.  The  deformity  due  to  the  rich  deposit  of  callus  disappears 
with  the  absorption  of  this  material.  When  all  or  any  portion  of  the 
entire  thickness  of  the  jaw  requii'es  removal  for  ostitis,  the  sub-perios- 
teal  operation  is  imperative,  since  by  this  means  alone  is  it  possible  to 
have  a  reproduction  of  the  bone.     The  method  of  procedure,  when  the 


428 


A  TEXT-BOOK   ON   SURGERY. 


bone  is  tlic  seat  of  a  neoplasm,  depends  iij)on  tlie  character  of  the  new 
formation.  If  there  is  any  doubt  as  to  the  benign  character  of  the  tumor, 
a  i)iece  should  be  removed  and  examined  iiiicrosco])ical]y  liefoi-e  operation. 

In  sarcoma,  cancer,  and  enchondroma  of  the  jaw,  the  sub-periosteal 
operation  can  not  be  performed,  since  the  sound  tissues  must  be  included 
in  the  ablation,  in  order  to  secure  immunity  from  recurrence.  Enchon- 
droma, though  not  intrinsically  malignant,  tends  to  recur  if  not  freely 
excised. 

Operation. — When  it  is  safe  and  i)ossilile,  the  diseased  portion  of  the 
lower  jaw  should  be  removed  without  breaking  the  continuity  of  the 
bone.  If  a  portion  of  the  entire  thickness  of  the  organ  is  removed,  the 
tendency  to  displacement  is  inward,  thereby  interfering  with  mastica- 
tion. The  entire  thickness  of  the  jaw  should  be  included  in  exsection 
for  malignant  neoplasm. 

Partial  resection  of  the  upper  or  alveolar  portion  of  the  body  of  the 
lower  jaw  in  front  may  be  accomplished,  in  mild  cases,  from  within  the 
buccal  cavity.  When  the  disease  is  extensive,  proceed  as  follows  :  At  a 
distance  from  the  alveolar  margin  sufRcient  to  permit  the  exposure  of 
all  diseased  bone  make  an  incision  parallel  with  the  margin  of  the  lip, 
and  also  parallel  with  the  inferior  border  of  the  jaw.  This  incision  should 
extend  in  depth  to  the  bone  and  in  length  beyond  the  area  of  disease. 
The  bone  is  next  divided  by  tlie  chisel  and  mallet,  the  key-bole  saw,  or 
removed  in  small  pieces  by  the  ron- 
geur, in  the  line  indicated  in  Fig. 
500.  The  operation  is  concluded 
by  bringing  the  Hap  back  into  place 
with  silk  sutures. 

When  the  disease  is  more  gen- 
eral, necessitating  a  removal  of  the 


Fig. 


500. — Line  of  eection  in  removing  the  alveo- 
lus ot  the  lower  jaw.     (.\lter  Koser.) 


entire    thickness   of   the    bone,    a 

more  extensive  incision  is  required. 

The  lip  is  divided  in  the  median 

line  down  to  the  under  surface  of 

the    chin,    and    thence   along   the 

lower  border  of  the  jaw  (Fig.  501). 

When    the    ramus    and    articular 

process  requii-e  removal,  the  line  of  incision  may  be  carried  to  the  angle 

and  up  the  ramus.     In  disarticulation,  while  the  incision  through  the 

skin  can  be  safely  carried  as  high  as  the  zygoma,   the  incision  down 

to  the  bone  should  not  extend  farther  than  on  a  level  with  the  tip  of 


Fig.  501.— (.\ftcr  Koser.) 


THE  LOWER  JAW.  499 

the  mastoid  process,  for  fear  of  dividing  the  facial  nen-e.  From  this 
point  the  coi-acoid  process  and  the  articulation  may  be  reached  by  work- 
ing np  close  to  the  surface  of  the  bone,  beneath  the  periosteum  (if  the 
disease  is  not  malignant).  The  inferior  dental  artery  should  be  secured 
when  divided,  and  the  other  branches  of  the  internal  maxillary  avoid- 
ed. The  external  carotid  is  left  behind  the  ramus.  In  the  act  of  dis- 
articulation it  must  be  remembered  that  the  internal  carotid  artery  and 
internal  jugular  vein  enter  the  cranium  just  behind  the  vaginal  process 
of  the  temporal  bone,  which  forms  tlie  posterior  wall  of  the  articula- 
tion. As  this  i^rocess  is  only  al)out  one  eighth  of  an  inch  thick,  the  walls 
of  the  vein  and  artery  are  in  dangerous  proximity  to  the  attachment  of 
the  capsule.  The  anterior  and  outer  wall  of  the  capsule  should  be  first 
separated,  and  then,  while  strong  outward  traction  is  made  on  the  ramus, 
the  inner  wall  of  the  capsule  should  be  divided  as  close  to  the  neck  of 
the  bone  as  possible.  If  ablation  of  the  entire  bone  is  demanded,  this 
operation  is  repeated  for  the  opposite  side.  It  must  not  be  forgotten  that 
when  the  attachments  of  the  hyoid  muscles  to  the  jaw  are  severed,  the 
action  of  the  remaining  muscles,  together  with  gravity,  aid  in  carrying 
the  base  of  the  tongue  backward  upon  the  glottis,  producing  dangerous 
if  not  fatal  asphyxia.  The  precaution  of  passing  a  thread  through  the 
tip  of  the  tongue  should  not  be  overlooked. 

Resection  of  the  inferior  dental  nerve  may  be  performed  at  the  men- 
tal foramen,  or  at  the  commencement  of  the  dental  canal  at  the  angle 
of  the  jaw. 

The  mental  foramen  is  situated  about  half  way  between  the  inferior 
border  of  the  bone  and  the  alveolar  border  or  necks  of  the  teeth.  A 
line  let  fall  perpendicularly  from  the  interspace  between  the  two  bicuspid 
teeth  of  the  lower  jaw  Avill  jiass  over  the  ojiening.  A  curved  or  crucial 
incision  will  expose  the  nerve  at  this  point. 

The  foramen  of  entrance  of  the  inferior  dental  nerve  is  very  near  the 
center  of  the  qiiadrilateral  formed  by  the  anterior  and  posterior  margins 
of  the  ramus,  the  lower  horizontal  border  of  the  angle,  and  an  imaginary 
horizontal  line  on  a  level  with  the  lowest  portion  of  the  sigmoid  notch. 

An  incision  about  two  inches  long  and  slightly  curved  is  made  so 
that  its  middle  will  be  about  the  center  of  the  parallelogram  above  de- 
scribed. The  trephine  should  be  applied  over  the  center  of  the  quadri- 
lateral. The  best  indication  of  having  reached  the  nerve  is  the  bleeding 
through  the  track  of  the  trephine  when  it  passes  into  the  cancellous  tis- 
sue of  the  jaw.  This  comes  from  the  wounded  inferior  dental  vessels. 
An  elevator  placed  in  the  cut  will  now  lift  the  button  of  bone,  and  the 
nerve  is  exposed.  The  entire  portion  in  the  limit  of  the  trephine  should 
be  excised.  Temporary  relief  is  almost  invarialdy  secured,  although  a 
recurrence  of  pain  is  not  uncommon  after  several  months. 

Anchylosis. — Motion  of  the  jaw  may  be  limited  or  entirely  prevented 
by  muscular  rigidity,  cicatricial  contractions,  or  true  anchylosis  at  the 
temporo-maxillary  articulation. 

The  area  of  motion  in  partial  anch^vlosis  may  be  increased  by  forcible 
separation  of  the  lower  from  the  ujjper  jaw  by  the  apparatus  shown  in 


430 


A  TEXT-BOOK  OX  SURGERY. 


Fig.  37.  This  should  he  repeated  at  frequent  intervals,  gradually  in- 
creasing the  pressure.  In  severe  cases  a  false  joint  may  be  successfully 
established  by  section  of  the  bone  nntf^rior  to  the  point  of  fixation,  usuiil- 
ly  at  or  above  the  angle.  Care  must  l)e  taken  to  make  frequent  pas- 
sive motion  in  order  to  prevent  union  of  the  divided  ends. 


Fia.  502. — Incisor,  straight  root. 


Fio.  503. — Incisor,  half-curved  root. 


Tino  Tektii. 

Extraction. — Dental  forceps  should  be  of  different  patterns,  the  jaws 
bent  at  various  angles  to  the  shaft,  and  the  handles  large  enough  to  be 
grasped  firmly  and  securely  by  the  operator. 

The  gum  immediately  around  the  neck  of  the  tooth  should  be  free- 
ly incised  Avith  a  lancet,  since  if  this  precaution  is  not  taken  it  may 

be  unnecessarily  torn 
away  with  the  tooth. 
The  injection  of  cocaine 
around  the  tooth  will 
render  the  cutting  pain- 
less. The  jaws  of  the 
forceps  are  applied  on 
either  side  of  the  neck, 
and  forced  down  to- 
ward the  root  until  they 
grasp  the  tooth  firmly 
at  the  margin  of  its 
alveolar  insertion.  The 
direction  of  traction  is  determined  by  the  normal  direction  of  the 
axis  of  the  tooth.  In  extracting  the  incisors  and  canine  teeth,  the  for- 
ceps represented  in  Figs.  502  and  503  are  applied  as  described  above, 
and,  when  firmly  fixed, 
a  slight  forward  and 
backward  movement, 
with  limited  rotation, 
will  loosen  the  root, 
while  traction  should 
at  the  same  time  be 
made  in  a  direction 
upward  and  slightly 
forward  for  the  low- 
er jaw,  and  do^^•nward 
for  the  teeth  of  the 
upper  row.  For  the 
bicuspids  and  molars, 
the  instruments  shown 
in  Figs.  504,  505,  and 
506  are  preferable. 

The  bicuspids  and  molars  may  be  loosened  by  lateral  motion  or  rock- 


fiG.  504.— Wolverton's  upper  bicuspids. 


Fio.  505.— Wolverton's  lower  bicuspids. 


THE  PALATE. 


431 


ing.  The  direction  of  traction  is  slightly  inward  for  the  lower  teeth,  and 
slightly  outward  for  those  of  the  upper  jaw. 

Fracture  of  a  root  or  shelving  of  the  alveolus  wiU  occur  at  times 
in  the  most  skillful 
hands,  and  abscess 
and  necrosis  may  en- 
sue. Fragments  of 
the  teeth  should  be 
gouged  out  by  using 
an  elevator.  Hfemor- 
rhage,  usually  insig- 
niticant,  may  at  times 
be  dangerous,  death 
having  occurred  from 
this  cause  in  one  or 
moi'e  instances.    Cold 

or  heat,  or  packing  the  cavity  with  a  compress  of  cotton  or  lint,  will 
effect  its  ari'est.  In  extreme  cases  the  compress  may  be  saturated  with 
MoDsel's  solution,  or  alum,  or  any  astringent,  and  left  in  for  forty-eight 
hours.  Anaesthetics  may  be  employed  with  great  safety  in  dental  surgery. 
Nitrous  oxide  is  of  every-day  use,  and  ether  is  both  safe  and  effective. 
ChlorofoiTu  is  not  to  be  employed  unless,  after  full  infonnation,  the  x«- 
tient  relieves  the  operator  of  all  responsibility.  When  ether  or  chloro- 
form are  administered,  the  patient  should  be  placed  in  the  recumbent 
posture. 


Fifl.  506. — Harris's  lower  molars,  tor  tlie  two  sides. 


The  Palate. 

Uvula. — On  account  of  elongation  or  hypertrophy  of  this  portion  of 
the  soft  palate,  its  excision  is  at  times  required.  It  may  be  accomplished 
by  taking  hold  of  the  tip  with  a  mouse-tooth  forceps,  and  with  a  long 
curved  scissors  removing  as  much  as  required.  Complete  local  anjesthe- 
sia  may  be  obtained  by  mopping  the  uvula  with  a  small  quantity  of  a 
4-per-cent  solution  of  cocaine  hydrochlorate  at  intervals  of  three  min- 
utes for  tifteen  minutes  before  the  operation. 

Tumors  of  the  palate,  abscess,  necrosis,  and  xilceration  are  not  infre- 
quent, and  demand  the  same  treatment  as  in  other  portions  of  the  body. 

Cleft  jKilate  may  be  confined  to  the  soft  palate  ;  it  may  include  with 
this  a  portion  or  all  of  the  hard  palate  and  alveolus,  or  it  may  be  con- 
lined  to  the  hard  palate  alone.  It  is  usually  congenital,  although  it 
may  be  acquired,  as  in  the  perforations  which  ensue  as  a  result  of  syphi- 
litic ulceration  and  necrosis. 

The  cleft  in  the  hard  palate  is  most  often  single,  the  vomer  being 
attached  to  one  side  of  the  palate-process  of  the  superior  maxilla  (Fig. 
460).  Occasionally  it  is  double,  there  being  a  central  piece — the  vomer — 
which  runs  forward  and  is  attached  to  the  pre-maxillary  bone  (Fig.  401). 

Treatment. — When  a  hare-lip  exists  as  a  complication  of  cleft  palate, 
the  oi^eration  on  the  lip  should  lirst  be  made  in  order  to  enable  the  child 


432 


A  TEXT-BOOK   ON   SURGERY. 


to  swallow  sufficient  ncmrishnient,  und  to  gain  tlie  additional  advantage  of 
pressure  of  the  united  lip,  wliich  aids  in  approximation  of  the  edges  of 
the  cleft  in  the  hard  palate. 

Tlie  most  suitable  age  for  opei-iting  is  within  the  first  three  years  of 
life,  if  the  infant  is  sufficiently  strong  and  well  nourished  to  endure  so 
formidable  a  procedure.  One  of  tiie  most  discouraging  features  of  this 
operation,  if  postponed  until  later,  is  that,  owing  to  the  shortening  and 
failure  of  development  in  the  palate  muscles,  it  is  practically  impossible 
to  acquire  a  natural  arliiiilation,  even  after  the  fissure  has  been  success- 
fully closed. 

When  the  cleft  is  genei-al— that  is,  entirely  through  the  soft  and  hard 
palate— it  is  advisable  to  close  the  soft  portion  first  and  finish  the  re- 
mainder in  one  or  more  sittings,  as  may  be  found  necessary.  In  chil- 
dren, chloiofoiTn  should  be  used;  in  adults,  a  sufficient  degree  of  local 
an?pstliesia  may  be  obtained  by  the  employment  of  hydrochlorate  of  co- 
caine to  enable  the  operation  to  be  done  with  the  very  valuable  aid  of 
the  ])atient. 

In  a  case  operated  upon  by  myself,  the  parts  to  be  incised  were 
brushed  over  with  a  4-per-cent  solution  of  cocaine  at  intervals  of  two  or 
three  minutes  tov  half  an  houi'  preceding,  and  about  every  five  minutes 
during,  the  operation.  The  anaesthesia  was  perfectly  satisfactory,  and 
complete  union  resulted  after  the  first  operation. 

OjH'rafion  of  Stapliylorrapliy. — The  first  object  in  this  operation  is 
to  keep  the  mouth  of  the  patient  widely  opened.  For  this  purpose 
GoodwilUe's  gag  Is  the  best  of  all  instruments  (Figs.  35  and  8G).     The 

tongue  may  be  depressed 
with  a  simtula  if  neces- 
sary. If  an  anaesthetic  is 
employed,  the  condition  of 
narcosis  should  not  be  pro- 
found, for,  if  laryngeal  sen- 
sibility is  completely  lost, 
blood  or  mucus  may  pass 
into  the  larynx  and  trachea 
instead  of  being  swallowed. 
The  patient's  head  being 
firmly  held  by  an  assistant, 
the  soft  palate  is  seized 
by  a  mouse-tooth  fixation- 
forceps,  and  with  a  blunt- 
pointed,  long  narrow  knife 
(Fig.  .50)  a  strip,  about  one 
eighth  to  one  sixteenth  of 
an  inch  wide,  is  removed 
from  the  edges  of  the  fis- 


Fio.  507.— Froslicnin^  the  mnrgin  of  the  cleft  in  the  operation 
of  btiipliylon-aphy.     (After  Malgaigne.) 


sure,  in  its  entire  length 
(Fig.  .507).  In  order  to  steady  the  palate,  a  silk  thread  may  be  inserted 
on  either  angle,  or  a  second  forceps  a][)plied,  although  this  is  not  always 


THE   PALATE.  433 

necessary.  The  entire  margin  of  the  cleft  must  be  carefully  freshened, 
for  if  any  point  is  left  uncut  union  will  fail.  The  bleeding  is  next 
arrested  by  small  sponges,  on  staffs  (Fig.  83),  dipped  in  ice-water  and 
squeezed  dry. 

In  uniting  the  freshened  edges.  Dr.  Goodwillie's  hollow  needle  (Fig. 


Fig.  508. — Goodwillie's  hollow  needle  for  silk-worra  gut  suture  in  the  closure  of  clefl  palate. 

508)  is  the  best  instrument,  while  the  silk-worm  gut  suture  leaves  noth- 
ing to  be  desired  in  this  operation. 

To  the  shaft  adjust  one  of  the  needles  which,  from  its  shape,  is  best 
adapted  to  the  peculiar  form  of  the  fissure  to  be  closed,  and  push  one  of 
the  silk- worm  bristles  through  from  the  butt  to  the  point  until  it  projects, 
and  then  draw  it  back  one  eighth  of  an  inch  within  the  eye  of  the  needle. 
Seize  the  edge  of  the  flap  with  the  forceps,  and  at  a  point  between  one 
eighth  and  one  fourth  of  an  inch  from  the  freshened  margin  of  the  fissure 
insert  the  needle  from  before  backward,  through  the  side  corresj^onding 
to  the  operator's  right  hand  (left  side  of  the  patient),  and  then  through 
the  opposite  side,  at  a  like  point  from  behind  forward.  In  order  to 
facilitate  the  passage  of  the  needle,  the  flap  must  be  held  steadily  with 
the  forceps.  As  soon  as  the  needle  has  transfixed  the  second  flap  and 
the  eye  is  visible,  the  operator  pushes  on  the  bristle  at  the  butt  of  the 
needle-holder,  causing  the  other  end  to  come  out  of  the  eye  of  the  needle, 
when  it  is  seized  with  the  forceps  and  drawn  forward.  Holding  this  end 
firmly,  the  needle  is  withdrawn,  leaving  the  suture  in  position.  The  ends 
of  this  are  now  fastened  together  with  a  perforated  shot,  and  held  aside 
until  all  are  inserted.  The  sutures  should  be  about  one  fourth  of  an  inch 
apart.  When  the  last  one  is  inserted,  the  operator  ties  one  after  another 
from  above  downward.  The  first  knot  is  single,  and  this  is  run  down 
tight  and  repeated  with  two  additional  knots  to  secure  it.  The  ends  are 
then  cut  oflf,  one  fourth  of  an  inch  from  the  knot.  This  material  ties 
easily,  does  not  slip  or  break,  is  not  absorbable,  and  holds  its  place  until 
removed. 

After  the  sutures  are  tied  it  will  be  observed  that  (as  a  result  of  the 
fissure,  the  levator  pnlati  and  palato-pharyngeus  muscles  being  shortened) 
there  is  now  marked  tension  of  the  soft  palate,  which,  if  not  relieved, 
will  pull  upon  the  sutures  and  cause  separation  of  the  edges  of  the 
wound.  To  obviate  this,  a  sharp  knife  (Fig.  55)  is  thrust  through  the 
palate,  about  the  center  of  the  posterior  margin  of  the  horizontal  plate 
of  the  palate-bone  of  that  side,  and  an  incision  made,  in  a  direction 
downward  and  outward,  to  within  from  one  fourth  to  one  half  of  an 
inch  from  the  free  border  of  the  palate,  near  the  hamular  ])rocess,  as  in 

28 


434 


A  TEXT-BOOK   ON   SURGERY. 


Fig.  509.  This  incision  divides  the  levator  palati  of  either  side.  The 
anterior  and  posterior  pillars  of  the  fauces  should  also  be  snipped  with 
dull-pointed  scissors.  All  of  these  wounds  close  later  by  granulation. 
It  is  important  to  keei)  the  muscles  of  this  region  at  rest  for  a  week  after 
the  operation. 

When  the  cleft  extends  into  the  linid  palate,  as  shown  in  Fig.  510, 
the  lissure  may  be  closed  by  sliding  the  membrane  lining  the  vault  of  the 
palate. 


Fio.  509.— (After  Agnew.) 


Fio.  510. — Incisions  in  sliding  the  periosteum  for  clos- 
ure of  the  bony  cleft,    (ilodified  from  Koenij;.) 


The  edges  of  the  fissured  soft  palate  are  freshened,  as  in  the  preceding 
operation.  Along  the  edges  of  the  bony  fissure  an  incision  {a  h,  Fig.  510) 
is  made,  with  a  knife  shaped  like  a  gum-lancet  (Fig.  57),  and,  by  the  aid 
of  curved  elevators  (Fig.  71),  the  membi-ane  lining  the  bony  palate  is 
carefully  lifted  with  the  periosteum.  Another  incision  is  now  made  on 
either  side  of  the  fissure,  close  to  and  parallel  with  the  junction  of  the 
alveolus  with  the  palate  processes,  A  7?,  through  which  the  elevator  is 
again  introduced,  and  the  periosteum  lifted  until  the  whole  flap  included 
between  B  A  and  the  edges  of  the  fissure  a  b  is  detached.  If  severe 
haemorrhage  follows  the  incision,  the  wound  should  be  temporarily 
packed  with  lint,  or  pressure  with  the  finger  may  arrest  the  bleeding. 

The  flaps  are  now  ready  for  sliding,  and  the  sutures  are  introduced 
along  the  freshened  edges,  as  in  the  preceding  operation. 

When  the  cleft  extends  still  farther  forward  through  the  alveolus, 
and  the  fissure  is  wide,  it  will  become  necessary  to  carry  the  palate  pro- 
cesses toward  the  median  line  by  an  osteoplastic  operation.  In  this 
procedure  no  effort  is  made  at  lifting  the  periosteum,  and  it  is  better  to 
attempt  the  approximation  of  only  one  portion  of  the  cleft  at  a  sitting. 
In  order  to  secure  all  the  nutrition  possible,  the  soft  palate  should  be 


THE  TONGUE  AND   BUCCAL  CAVITY. 


435 


first  united.  The  anterior  or  posterior  portion  of  the  bony  fissure  may 
be  closed  at  the  next  operation,  as  follows :  Freshen  the  edges  of  the  soft 
parts  along  the  fissure.  Drill  two  holes  tlirough  the  bony  palate  of  either 
side,  one  fourth  of  an  inch  distant  from  the  edges  to  be  approximated, 
and  insert  two  strong  silver  wires,  as  shown  in  Fig.  511.  On  either  side, 
close  to  and  parallel  with  the  alveolus,  make  two  incisions  through  to 
the  bone,  as  at  A  B  (Fig.  510),  and  di'ill  with  an  awl  a  series  of  holes  in 
the  track  of  these  incisions.  A  few  strokes  of 
a  small  chisel  will  now  break  the  palate  pro- 
cesses in  tlie  line  of  the  holes,  when,  by  twist- 
ing the  wires,  the  loosened  plates  will  be  ap- 
proximated in  the  median  line.  After  union 
has  occurred  in  this  portion  of  the  cleft,  the 
operation  may  be  completed  in  the  anterior  por- 
tion, by  drilling  the  palate  and  alveolus,  and 
breaking  this  last  through  from  the  fi^ont  with 
a  chisel,  approximating  the  sides  as  above. 

Perforations  of  the  palate  are  treated  prac- 
tically in  the  same  way  as  congenital  cleft,  by 
freshening  the  edges,  and,  if  necessary,  sliding 
the  periosteum,  as  above  given. 


Fio.  511.— (After  Agnew.) 


The  Tongue  and  Buccal  Cavitt. 

Wounds  of  the  tongue  bleed  profusely,  especially  if  the  larger  vessels 
along  its  under  surface  are  divided.  The  arrest  of  haemorrhage  is  easily 
and  safely  accomplished  by  introducing  the  index-finger  well  back  over 
the  dorsum  to  the  root  of  the  tongue,  and  bringing  the  organ  well  for- 
ward and  forcibly  compressing  it  against  the  symphysis  menti.  The  tip 
of  the  organ  should  be  turned  upward,  and  the  forceps  applied  at  the 
bleeding  points.  In  the  substance  of  the  tongue  the  vessels  are  also 
readily  secured  in  the  same  manner.  Should  any  difficulty  arise,  a  silk 
thread  may  be  carried  around  the  I>leeding  vessel  by  means  of  a  curved 
needle,  or  it  may  be  transfixed  with  a  tenaculum  and  the  thread  tied 
around  the  hook. 

Glossitis — Hemiglossitis. — Inflammation  of  the  tongue  may  result 
from  the  same  causes  and  assume  all  the  phases  of  inflammation  common 
to  the  soft  tissues  in  other  portions  of  the  body.  It  may  be  acute  or 
chronic,  ending  in  ulceration  or  hypertrophy.  Tlie  process  may  begin 
superficially,  as  after  the  ingestion  of  some  irritating  substance,  or  it 
may  commence  in  the  deeper  porticms  of  the  organ  as  a  diffuse  phleg- 
monous process.  In  some  instances  only  one  lateral  half  of  the  organ 
is  involved. 

Treatment. — Inflammation  of  the  tongue  from  any  cause  should  be 
closely  watched,  on  account  of  the  danger  of  asphyxia  from  rapid  en- 
largement of  this  organ.  In  this  emergency  tracheotomy  should  be 
performed.     If  abscess  forms,  incision  or  j)uncture  is  demanded.    Scarifi- 


436  A  TEXT-BOOK  ON    SURGERY. 

cation  may  be  required  in  rapid  enlargement  of  this  organ  from  engorge- 
ment of  the  vessels. 

lliipcrtroiihi/  of  tlie  tongue  is  both  congenital  and  acquired.  It  may 
exist  in  adult  life,  although  it  is  in  general  a  condition  of  childhood. 
The  enlargement  is  due  to  hypertrophy  of  the  lymphatic  plexuses  of 
this  organ  and  to  a  general  liyperplasia  of  the  oonne(^tive-tissue  elements. 
The  muscular  substance  undergoes  granular  metamorphosis.  Tlie  cause 
of  this  disease  is  n(jt  understood.  The  organ  may  become  so  large  that 
it  protrudes  from  the  mouth,  pushes  the  teeth  out  of  their  normal  po- 
sition, and  interferes  with  deglutition  and  respiration  to  such  an  extent 
that  its  ])artial  or  complete  removal  becomes  necessary.  Cystic  tumors 
of  the  tongue  may  be  mistaken  for  hypertrophy.  A  diagnosis  may  be 
made  by  exploration  with  a  good-sized  aspirator-needle. 

In  mild  cases  deligation  of  the  lingual  artery  of  one  or  both  sides 
may  be  done,  and  this  may  be  followed  by  excision  of  a  portion  of  the 
organ.  The  tip  may  be  amputated,  or  a  triangular  section  may  be  re- 
moved from  the  central  portion,  the  sides  being  brought  together  by 
sutures. 

Atrophy  is  a  rare  disease,  and  is  due  to  diminution  of  the  blood- 
supply,  or  to  lesions  of  the  trophic  nerves  of  this  organ. 

Cystic  tumors  of  the  tongue  may  be  caused  by  closure  of  the  outlet 
to  any  portion  of  the  follicidar  apparatus  (retention-cysts),  or  less  fre- 
quently l)y  the  lodgment  in  this  organ  of  a  parasite,  the  cystlcercus. 

The  diagnosis  is  made  positive  by  exploration.  The  treatment  re- 
quired is  excision  of  the  sac  with  the  scissors,  or  the  less  bloody  oper- 
ation of  opening  it  with  the  Paquelin  cautery,  burning  the  lining  mem- 
brane thoroughly,  and  packing  the  cavity  with  iodoformized  gauze. 
The  precaution  should  be  taken  to  make  the  packing  from  one  piece  of 
gauze,  and  of  securing  it  by  a  thread  attached  outside,  in  order  to  pre- 
vent its  accidental  escape  backward. 

Angioma  of  the  tongue  is  rare.  When  present,  the  treatment  is  re- 
moval by  the  ligature,  or  by  injection  with  50-per-cent  carbolic-acid 
solution. 

Abscess  of  the  tongue  should  be  treated  by  aspii-ation,  and  hyper- 
distention  of  the  sac  with  l-to-3000  sublimate  solution.  If  this  does  not 
succeed,  an  incision  should  be  made  and  drainage  secured. 

Ulcers  of  the  tongue  appear  as  a  symptom  of  various  conditions. 
They  occur  in  syphilis  with  great  frequency.  They  may  occur  as  a 
i-esult  of  general  catarrh  of  the  pharynx  and  mouth,  or  as  a  result  of  any 
violence.  If  an  ulcer  exists  as  an  expression  of  a  dyscrasia,  the  treat- 
ment must  be  chiefly  constitutional.  The  local  treatment  consists  in 
cleanliness  and  the  application  of  nitrate  of  silver,  or  other  stimulating 
remedies. 

The  tongue  is  at  times  the  seat  of  ■papiUoina,  lipoma,  fibroma,  sar- 
coma, and  one  or  two  instances  of  encJcoiid ronia  in  this  organ  are  re- 
ported. EpitJieliom.a  is  not  infrequent,  and  is  the  most  important  of 
the  neoplasms  of  this  organ,  not  only  on  account  of  its  greater  frequency, 
but  also  on  account  of  its  grave  character  and  the  necessity  of  ari-iving 


THE  TONGUE  AND  BUCCAL  CAVITY.         437 

at  an  early  diagnosis  of  the  disease.  The  late  manifestations  of  syphilis 
(ulcers,  gumma,  fissures),  ulcers  of  tuberculosis,  and  some  speciiic  iilcers, 
and  papilloma,  may  be  mistaken  for  this  neoplasm. 

If  a  patient  has  a  syphilitic  liistory,  gunmia  or  specific  ulcer  will 
naturally  be  suspected.  If  large  doses  of  j)otassium  iodide  be  adminis- 
tered for  two  or  three  weeks,  the  speciiic  ulcer  will  respond  to  this  rem- 
edy. If  no  impression  is  made  upon  it,  it  should  be  treated  as  ma- 
lignant. As  regards  all  other  suspicious  sores  of  this  organ,  it  will  be 
the  wiser  ])ractice  to  treat  them  also  as  malignant  growths,  for  it  is  a 
well-recognized  fact  that  papillomatous,  tuberculous,  and  simple  ulcers 
of  the  tongue  (as  elsewhere),  chronic  in  character,  are  capable  of  trans- 
formation into  epithelioma.  If  these  sores  are  removed  early  in  their 
history,  no  mutilation  is  required,  the  operation  is  without  danger,  only 
a  small  portion  of  the  organ  need  be  sacrificed,  and  the  focus  of  dis- 
ease is  removed  before  its  malignant  nature  is  declared  or  metastasis 
occurs.  If  an  epitheliomatous  ulcer  exists,  its  character  may  be  deter- 
mined by  microscopical  examination,  as  given  by  Butlin.*  If  the  scrap- 
ing from  a  tuberculous,  syphilitic,  or  simple  ulcer  is  placed  in  a  drop  of 
water  on  a  slide,  pus-  and  blood-corpuscles,  particles  of  food,  bacteria, 
and  a  few  normal  or  almost  normal  epithelial  cells,  are  observed.  If 
the  scraping  from  an  epitheliomatous  ulcer  be  examined,  in  addition  to 
the  above  will  be  seen  a  great  number  of  abnormal  epithelia,  varying  in 
size  and  shape,  some  flattened  scales,  others  round  or  oval,  others  elon- 
gated, with  caudate  prolongations.  The  cells  are  generally  granular,  and 
possess  from  two  to  three  or  more  nuclei,  much  larger  than  the  normal 
nuclei  of  these  cells.  In  some  instances  the  "swallow's-nest "'  arrange- 
ment may  be  observed. 

If  no  ulcer  is  present,  a  section  for  microscopical  examination  may  be 
removed  from  the  indurated  mass. 

Operation. — The  method  of  procedure  must  be  determined  by  the 
extent  of  the  organ  to  be  removed.  If  the  induration  is  confined  to  the 
tip,  and  does  not  extend  more  than  one  inch  behind  this  point,  the  line 
of  section  should  be  at  or  near  the  center  of  the  tongue.  It  should  al- 
ways be  well  away  from  the  disease.  An  inch  from  the  nearest  indura- 
tion will  be  safer  than  to  allow  the  line  of  section  to  approach  the  neo- 
plasm in  order  to  save  more  of  the  tongue.  When  the  lateral  aspect  of 
the  anterior  half  is  involved,  the  line  of  section  need  not  pass  at  right 
angles  to  the  axis  of  the  organ,  but  may  curve  around  parallel  with  the 
limit  of  induration  at  a  sufficient  distance  from  it.  In  this  way  the  an- 
terior portion  of  the  opposite  half  may  be,  in  part,  preserved.  If  the 
floor  of  the  mouth  is  infiltrated,  it  should  be  dissected  from  its  attach- 
ments to  the  jaw,  and  the  diseased  part  removed  with  the  tongue.  If 
the  disease  extends  to  the  middle  of  the  tongue,  and  involves  its  entire 
width,  the  organ  should  be  removed  at  its  base,  and  the  floor  of  the 
mouth  thoroughly  cleared  of  all  suspicious  tissue.  The  lymphatics  in 
the  middle  line  below  the  symphysis  menti,  in  the  submaxillary  region 

*  "  Diseases  of  th o  Tongue,"  Lea  Brothers  &  Co.,  Philadolpliia,  1885. 


438  A  TEXT-BOOK  ON  SURGERY. 

and  down  the  neck,  should  be  examined  and  removed  if  metastasis  has 
occurred. 

When  the  floor  of  tlie  Tiioutli,  t(>,ti:('tlier  witli  the  nnterior  two  thirds 
of  the  organ,  are  involved,  and  inetastasis  is  evident  in  the  deeper  lym- 
phatics, the  propriety  of  surgical  interference  is  questionable.  A  cure 
is  not  probable,  and  the  operation  f()riiiidal>l('  and  dangerous.  The  re- 
moval of  the  ulcerating  i)ortion  may  be  done  as  a  palliative  measure. 

Without  regard  to  the  manner  in  which  the  oi)eration  is  to  be  per- 
formed, the  ether  shoidd  be  administered  at  lirst  through  tlu^  mouth, 
and,  after  the  narcosis  is  complete,  when  it  becomes  necessary  to  work 
within  this  cavity,  the  anjesthesia  should  be  carefully  continued  by  the 
rectum.  It  is  essential  for  the  teeth  to  be  held  widely  separated  by  the 
gag  (Fig.  36),  and  the  lips  held  out  of  the  way  by  tlat,  blunt  retractors. 

In  mild  cases,  where  the  disease  is  situated  near  the  tip  of  the  organ, 
and  where  the  floor  of  the  mouth  is  not  involved,  the  operation  may  be 
done  with  the  galvano-cautery  loop,  as  follows  :  The  tongue  shoidd  be 
drawn  well  out  of  the  mouth  and  transfixed  from  its  under  surface  with 
a  strong  needle  (armed  with  a  heavy  silk  thread)  at  a  point  in  the 
healthy  tissue  where  the  section  is  to  be  made.  One  end  of  the  wire  of 
a  galvano-cautery  battery  is  fastened  to  the  thread,  drawn  through  the 
tongue,  attached  to  the  ecraseur  apparatus,  and  the  loop  tightened  so 
as  to  grasp  the  organ  in  the  direction  it  is  desired  to  make  the  section. 
When  it  is  not  divided  entirely  across,  the  antero-posterior  section  is 
first  made.  The  wire  is  now  slowly  heated  to  a  red  color,  and  the  loop 
is  very  slowly  tightened  and  drawn  through  the  organ.  If  it  is  made  to 
cut  through  quickly,  the  vessels  may  not  be  occluded.  The  transverse 
section  is  next  made  in  the  same  way,  and,  if  any  attachments  to  the 
floor  of  the  mouth  remain,  these  may  also  be  divided  by  throwing  the 
loop  around  them. 

If  the  cautery  battery  is  not  at  hand,  the  Paquelin  thermo-cautery 
may  be  employed. 

If  neither  of  these  more  modern  instruments  are  to  be  had,  the  ecra- 
seur will  suffice.  It  is  not  only  efficient,  but  is  less  apt  to  get  out  of 
order  than  the  other  apparatus.  When  the  lingual  arteries  have  not 
been  tied,  hemorrhage  is  apt  to  occur  after  section  with  either  of  these 
instruments.  It  may  be  aiTested  and  controlled  as  directed  in  wounds 
of  this  organ. 

When  a  more  extensive  operation  is  required,  the  following  method 
will  be  advisable  : 

A  careful  examination  of  the  lymphatic  glands  of  the  submaxillary 
and  cervical  regions  should  be  made,  and  if  any  induration  is  discovered 
they  should  be  removed  as  the  first  step  in  the  operation.  If  the  dis- 
ease has  existed  for  several  months,  in  all  probability  metastasis  has 
occurred,  even  when  the  enlargement  of  the  glands  can  not  be  detected 
by  palpation.  This  condition  is  especially  apt  to  exist  in  the  glands  cor- 
responding to  that  side  of  the  tongue  upon  which  the  disease  originated. 
It  is,  therefore,  a  wise  precaution  to  tie  the  lingual  artery  of  that  side, 
since  this  not  only  lessens  the  danger  of  hsemorrhage  in  the  removal  of 


THE   TONGUE  AND   BUCCAL  CAVITY.  439 

the  tongue,  but  exposes  the  glands  of  the  submaxillary  and  upper  cer- 
vical triangles,  and  facilitates  their  removal  if  involved.  The  operation 
of  tying  this  artery  has  been  given  on  page  246.  It  can  readily  be  secured 
opposite  the  central  tendon  of  the  digastric  muscle,  at  which  point  it 
is  almost  always  situated  half  way  between  the  insertion  of  this  tendon 
and  the  hypoglossal  nerve,  which  is  from  a  quarter  to  a  half  inch  above. 
In  two  instances  I  have  divided  the  posterior  belly  of  this  muscle  in  order 
to  expose  the  vessel  thoroughly.  When  this  is  accomplished,  the  wound 
should  be  irrigated  with  sublimate  (1  to  3UUI)),  a  drainage-tube  inserted, 
and  the  sutures  applied. 

The  ether  should  at  this  stage  of  the  operation  be  transferred  to  the 
rectum,  the  gag  inserted,  and  the  lips  retracted. 

It  is  important,  in  dissecting  out  the  floor  of  the  mouth  and  the  tongue, 
to  be  able  to  control  all  hsemorrhage  and  at  the  same  time  to  fix  the  tongue. 
This  may  be  accomplished  in  a  most  satisfactory  manner,  and  may  be 
considered  as  the  second  step  in  this  operation.  An  incision  about  an 
inch  long  is  made  in  the  median  line,  commencing  at  the  hyoid  bone 
and  extending  toward  the  symphysis.  By  this  incision  the  integument 
and  deep  fascia  are  divided.  A  long  steel  needle,  with  the  eye  at  the 
point  (Peaslee's  instrument  will  suffice),  armed  with  a  strong  silk  thread, 
is  introduced  through  the  wound,  and,  while  the  tongue  is  drawn  well 
forward,  the  point  of  the  needle  is  pushed  along  the  inner  surface  of 
the  lower  jaw  into  the  mouth  by  the  side  of  the  tongue  at  its  base. 
One  end  of  the  thread  is  pulled  out  through  the  mouth,  the  needle 
withdrawn,  and  the  end  of  the  thread  projecting  from  the  mouth  is 
again  carried  through  the  eye  of  the  needle.  This  is  now  introduced  by 
tiie  side  of  the  base  of  the  tongue  exactly  opposite  the  point  at  which 
it  entered,  and  is  brought  out  at  the  wound  below  the  chin.  A  strong 
wire  is  fastened  to  one  end  of  the  thread  and  is  pulled  into  the  mouth 
and  around  the  base  of  the  tongue  by  withdrawing  the  silk.  The  wire 
should  now  be  fastened  to  an  ecraseur  and  tightened  just  enough  to  con- 
trol the  bleeding.  In  this  manner  all  the  vessels  going  to  the  tcmgue 
and  the  floor  of  the  mouth  are  surrounded  and  controlled. 

The  third  stage  of  the  procedure  is  the  removal  of  the  tongue  and 
the  tissues  which  form  the  floor  of  the  mouth.  In  doing  this  the  Paque- 
lin  cautery-knife  will  be  found  exceedingly  useful.  If  it  is  not  at  hand, 
the  scissors  or  knife  may  be  used.  A  strong  silk  thread  should  be 
passed  through  the  sound  tissues  of  the  tongue  near  the  end  and 
intrusted  to  an  assistant.  It  is  tt)  be  used  in  lifting  the  organ  as  the 
dissection  proceeds.  The  attachment  along  the  lower  jaw  should  first 
be  divided  and  the  tissues  dissected  up  until  the  tongue  can  be  lifted 
freely  to  a  point  at  least  one  inch  behind  the  induration.  The  ecraseur- 
loop  should  now  be  placed  around  the  organ  and  the  division  made  at 
the  desired  point.  If  at  this  time  the  wire  loop  which  is  around  the  base 
of  the  tongue  is  fairly  tight,  no  bleeding  will  occur  after  the  amputation. 
If  gradually  loosened,  the  bleeding  points  on  the  stump  can  be  readily 
seized  with  the  long-nosed  narrow  forceps  and  tied  with  silk  ligatures. 
In  the  after-treatment  no  dressing  is  applied  to  the  wound  in  the  mouth. 


440 


A  TEXT-BOOK   ON  SURGERY. 


I  am  not  aware  that  this  method  of  controlling  hfcmorrhage  in  this  oper- 
ation has  been  performed  by  any  other  surgeon. 

When  the  inferior  maxilla  is  involved,  it  should  be  exsected  beyond 
the  limit  of  the  disease. 

If,  for  any  reason,  more  space  is  required  in  the  ablation  of  this 
organ  than  can  be  obtained  through  the  natural  orifice,  one  of  the  fol- 
lowing  jirocedures   may   be 
adopted : 

1.  Ganfs\m'\s](m  through 
the  cheek,  froiri  the  angle  of 
the  mouth  in  the  direction  of 
the  lobe  of  the  ear  as  far  as 
required  (Fig.  513,  a).  This 
incision  gives  a  full  view 
of  the  lateral  aspect  of  the 
tongtie,  and  may  be  made 
upon  both  sides  when  the 
disease  is  bilateral  and  ex- 
tends beyond  the  middle  of 
the  organ.  The  edges  of  the 
wound  are  afterward  brought 
together  by  hare-lip  pins  or 
silk  sutures. 

2.  Billroth    employs    a 
curved  incision  made  paral- 
lel with  the  arch  of  the  infe- 
rior maxilla  below  the  symphysis  (Fig.  512),  dividing  all  the  tissues  on 
this  line  until  the  floor  of  the  mouth  is  opened. 

3.  KocJter  has  lately  devised  an  operation  the  incision  in  which  is 
shown  by  the  line  h  dec  (Fig.  513).  A  preliminary  tracheotomy  is  done, 
and  the  pharynx  stuffed  with  a 
carbolized  sponge  to  which  a  string 
is  attached.  The  excision  extends 
along  the  anterior  border  of  the 
sterno-mastoid  muscle,  from  the 
level  of  the  lobule  of  the  ear  to 
the  level  of  the  hyoid  bone,  along 
this  bone  to  near  the  median  line, 
and  thence  to  the  symphysis  menti. 
The  skin  and  platysma  are  turned 
tip  on  the  jaw,  the  lingual  and  fa- 
cial arteries  and  veins  are  tied  as 
they  are  encountered,  all  enlarged 
glands  are  extirpated,  the  muscles 
and  floor  of  the  mouth  separated 
along  the  attachments  to  the  lower 
jaw   to  anv   required  extent.     If  „     „      ,    ..      ,„         ,  „   , 

,  .         -  .  ,  -,  *io.  513. — Incminn  of  Gant  and  Kocner. 

tlie  entu-e  tongue  is  to  be  removed,  (After  Butun.) 


Fig.  512.— Billroth's  incision.     (After  Butlin.) 


THE   TONGUE  AND   BUCCAL  CAVITY.  441 

the  opposite  lingual  is  also  tied.  Through  this  opening  the  tongue  is 
drawn  out,  dissected  from  its  anterior  and  lateral  attachments,  sur- 
rounded with  the  cautery-loop  and  divided,  or  cut  off  with  the  ecraseur 
or  scissors. 

In  the  after-treatment  the  trachea-tube  is  left  in  place,  and  the 
pharynx,  mouth,  and  wound  iilled  with  sponges  dipped  in  a  .5-per-cent 
carbolic-acid  solution,  the  excess  of  the  acid  being  washed  off  with 
water  before  the  sponges  are  applied.  The  wound  is  dressed  twice  a 
day,  and  liquid  nourishment  given  at  each  change  of  the  dressing. 

The  operation  of  Kocher  is  objectionable  on  account  of  the  extent  of 
the  dissection,  the  danger  of  submitting  such  a  large  wound  to  the  proba- 
bility of  septic  infection  from  the  mouth,  and  the  complication  of  trache- 
otomy. The  free  inspection  of  the  tissues  of  the  neck  which  it  permits, 
and  the  command  of  the  base  of  the  tongue  which  it  allows,  are  in  its 
favor. 

The  operations  in  which  the  organ  is  removed  through  the  mouth  are 
simpler,  require  much  less  time  in  execution,  and  should  be  preferred. 
If  the  author's  method  of  controlling  luemorrhage  is  adopted,  the  pro- 
cedure is  practically  bloodless,  and  a  preliminary  tracheotomy  is  there- 
fore unnecessary.  The  conditions  which  would  call  for  the  operations  of 
Uant,  Billroth,  or  Kocher  will  rarely  exist. 

The  after-treatment  consists  in  rinsing  the  mouth  at  frequent  inter- 
vals with  a  warm  solution  of  permanganate  of  potassa  (gr.  ss.  to  3J), 
anodynes  to  relieve  pain,  and  generous  liquid  diet. 

Banula. — This  name  is  applied  to  certain  tumors,  cystic  in  character, 
which  are  situated  immediately  beneath  the  anterior  and  lateral  portions 
of  the  tongue.  Ranula  is  usually  acquired,  although  it  may  be  congeni- 
tal. The  tumor  is  almost  always  single  ;  occasionally  there  is  one  on 
either  side  of  the  organ.  Commencing  as  a  result  of  obstruction  to  the 
outlet  of  one  of  the  subdivisions  of  the  sublingual  gland  (rarely  as  a 
result  of  occlusion  to  one  of  the  terminal  ducts),  it  may  grow,  when  left 
undisturbed,  to  great  size,  crowding  the  tongue  out  of  its  position,  rising 
above  the  level  of  the  teeth,  and  protruding  through  the  muscles  of  the 
chin  until  it  appears  beneath  the  skin  above  the  hyoid  bone. 

The  only  method  of  treatment  is  to  evacuate  the  contents  and  cau.se 
an  obliteration  of  the  sac  by  inflammatory  adhesion.  The  Paquelin  cau- 
tery is  the  best  instrument  to  employ  in  their  removal.  Etherize  the 
patient,  introduce  the  gag,  lift  the  tongue  upward  with  the  forceps, 
protect  the  lips  and  teeth  by  means  of  iiat  retractors,  seize  the  wall  of 
the  cyst  with  a  mouse-tooth  forceps,  and  with  the  platinum-knife  at  a 
red  heat  dissect  away  the  anterior  wall.  After  the  tluid  escapes,  dilate 
the  cavity,  and  make  a  thorough  digital  exjiloration  of  the  sac.  The 
cautery-knife  should  now  be  carried  slowly  back  to  the  deepest  portions, 
searing  all  sides  of  the  cyst-wall.  The  wound  should  be  well  packed 
with  a  single  piece  of  iodoformized  gauze.  The  after-treatment  consists 
in  changing  the  packing  every  twenty-four  to  forty-eight  hours,  and  at 
each  dressing  irrigating  the  cavity  with  l-to-2()00  sublimate  solutiiin. 

If  the  Paquelin  thermo-cautery  is  not  convenient,  seize  the  cyst-wall 


442  A  TEXT-BOOK   ON   SURGERY. 

with  the  forceps  and  dissect  it  out  witli  curved,  lilunt  scissors.  Pack  the 
wound  firmly  with  iodoformized  gauze,  as  above.  Haemorrhage  may  be 
controlled  as  directed  in  wounds  of  the  tongue. 

Toiiffue-Tie. — When  tlie  fr;enuni  extends  an  unusual  distance  toward 
the  tip  of  the  tongue,  or  is  so  narrow  that  it  checks  the  free  movements 
of  this  organ,  it  should  be  divided  in  the  following  manner :  Seize  tlie  tip 
of  the  tongue  with  a  dry  towel,  carry  it  upward  so  as  to  put  the  bridle 
on  the  stretch,  and,  with  a  curved  scissors,  divide  the  frsenum  from  one 
eighth  to  one  quarter  of  an  inch  nearer  to  the  floor  of  the  mouth  than  to 
the  surface  of  the  tongue.  This  precaution  is  necessary  to  avoid  wound- 
ing the  ranine  vessels.     The  gag  may  be  used  if  required. 

A  congenital  defect,  very  rarely  observed,  is  the  adhesion  of  the 
tongue  to  the  floor  of  the  mouth.  The  adhesions  should  be  broken  up 
at  birth,  and  the  operation  repeated  daily  until  free  mobility  is  secured. 

Equally  rare  is  the  bifid  or  snake-tongue,  which  results  from  arrest  of 
development  or  failure  of  union  of  the  two  halves  from  which  this  organ 
is  formed.  Tiie  edges  shoidd  be  pared,  and  the  two  halves  united  in  the 
median  line  by  sutures. 

Tonsils. — Acute  tonsillitis  is  of  very  frequent  occurrence,  causing, 
in  a  varying  degree,  pain,  difficulty  of  deglutition,  and  interference  with 
phonation,  deglutition,  and  respiration. 

The  patholoriy  of  this  affection  consists  in  dilatation  of  the  blood- 
and  lymph-vessels,  emigration  of  leucocytes,  and  proliferation  of  the 
connective  tissue  and  other  cell-elements  of  the  tonsil.  The  gland  rapidly 
enlarges,  producing  great  tension  of  the  pillars  of  the  fauces,  and  projects 
toward  the  median  line,  at  times  filling  the  pharynx  and  crowding  the 
velum  upward  and  backward. 

Acute  tonsillitis  may  end  in  resolution,  the  gland  rapidly  diminishing 
to  its  normal  size,  or  in  ulceration  or  suppuration  (abscess),  or  the  acute 
process  may  subside  into  a  chronic  form  of  inflammation,  which  induces 
permanent  hypertrophy  of  the  organ. 

The  local  treatment  of  acute  tonsillitis  consists  in  the  application  of 
hot  water  as  a  gargle,  and  scarification  of  these  organs  when  the  tension 
is  sufficient  to  produce  great  pain.  The  internal  administration  of  aco- 
nite tincture  and  quinine  is  highly  i-ecommended. 

Abscess  of  the  tonsil  should  be  opened  as  soon  as  its  presence  is  de- 
tected. The  discharge  of  pus  always  brings  great  relief.  If  the  symp- 
toms lead  to  the  suspicion  of  pus,  exploration  with  the  hypodermic  aspi- 
rator-needle should  be  made  to  determine  the  diagnosis.  The  internal 
carotid  artery  and  jugular  vein  are  well  back  from  the  tonsil,  on  a  level 
with  the  posterior  wall  of  the  pharynx. 

The  object  in  operating  early  is  to  prevent  oedema  of  the  glottis, 
which  may  occur  when  the  abscess  is  large  or  situated  behind  the  body 
of  the  tonsil.  A  more  remote  danger  is  i-upture  of  the  abscess  during 
sleep,  and  escape  of  the  contents  into  the  larynx. 

Chronic  hypertrophy  of  the  tonsils  should  be  treated  by  partial  ex- 
cision, repeated  as  often  as  may  be  deemed  necessary.  The  presence  of 
these  enlarged  organs  forces  the  patient  to  breathe  through  the  mouth. 


THE  TONGCTE  AND  BUCCAL   CAVITY. 


443 


a  habit  which  often  induces  a  catarrhal  condition  of  the  mucous  mem- 
brane lining  the  respiratory  tract.  The  follicles  of  the  tonsil  discharge 
a  dirty,  cheesy  secretion,  which  at  times  becomes  retained  in  the  gland 
and  undergoes  calcification.  Calculi  one  fourth  of  an  inch  in  diameter 
have  been  removed  from  this  organ. 

TonsiUotoiny. — Excisi<_)n  of  the  tonsils  is  an  operation  practically  free 
from  danger.     In  children  who  can  not  control  themselves,  chloroform 
should  be  used,  the  gag  in- 
troduced, and  the  tongue 
depressed  by  an  assistant. 
The    operator   seizes   the 
exposed    portion    of    the 
organ  with  a  long  mouse- 
tooth  forceps  or  a  tenaculum,  pulls  it  slightly  toward 
the  median  line,  and  with  a  long-handled  pair  of  scis- 
sors, curved  on  the  flat,  clips  off  from  one  third  to  one 
half  the  tonsil.     A  sponge,  fixed  in  a  holder,  dipped  in 
ice- water  and  pressed  on  to  the  bleeding  surface,  will 
arrest  the  hsemorrhage. 

In  adults  local  anaesthesia  may  be  insured  by  cocaine 
hydrochlorate,  and  the  operation  performed  as  above,  with  much  greater 
facility,  since  the  intelligent  co-operation  of  the  patient  is  of  great  value. 
If  the  long  scissors  can  not  be  had,  a  long,  curved,  probe-pcinted  bis- 


-i)^!^ 


Fig.  515.— Tiemann  &  Co.'s  tonsillotome. 


tonry  may  be  used  instead.  The  tonsil  is  lift- 
ed from  its  bed  by  a  tenaculum,  and  the  knife 
carried  through  as  above. 

Various  tunsillotomes  have  been  intro- 
duced, and  for  some  cases  are  very  useful,  but 
for  simplicity  and  general  application  the  in- 
struments above  selected  will  answer  all  pur- 
poses. Among  the  best  of  the  tonsillotomes 
is  that  of  Mackenzie  (Fig.  514),  and  Tiemann's  instrument  (Fig.  515). 

Tlie  tonsil  is  also  occasionally  the  seat  of  malignant  neoplasms,  as 
sarcoma  and  carcinoma,  while  cystic  tumors,  fibroma,  and  lymphoma  are 
among  the  benign  new  formations  which  attack  this  gland.  They  re- 
quire early  and  thorough  excision  in  aU  cases. 


CHAPTER  XV. 

THE  NECK. 

Wounds. — Wounds  of  the  neck  may  prove  rapidly  fatal  from  lispmor- 
rhatrf  inducing  synro])e  ;  from  hfpmi)nhap:e  into  tlip  trachea,  causing  fatal 
asj)liyxia  ;  from  the  entrance  of  air  into  the  veins  ;  or  from  injury  to  the 
cord,  at  or  near  the  medulla.  Death  from  sepsis  may  occur  as  a  more 
or  less  remote  sequence  of  a  wound  in  this  region. 

Treatment. — The  immediate  indications  are  to  arrest  haemorrhage  at 
once,  and  prevent  asphyxia,  either  by  obstruction  of  the  trachea  or  the 
admission  of  air  into  the  veins.  Haemorrhage  should  be  controlled  bj' 
pressure  directly  in  the  wound,  until  the  injured  vessels  can  be  secured 
by  the  ligature.  The  entrance  of  air  Into  the  veins  must  be  carefully 
prevented,  by  constant  pressure  on  the  cardiac  side  of  the  lesion,  until 
the  forceps  have  been  successfully  applied  at  the  bleeding  point. 

When  the  wound  is  incised  or  lacerated.,  and  is  above  the  hyoid  bone 
and  has  severed  the  hyoid  muscles,  in  addition  to  the  prevention  of 
haemorrhage  into  the  larynx  the  tongue  must  be  drawn  forward,  for 
when  these  muscles  are  divided  it  falls  back  upon  the  glottis,  and  may 
occlude  the  larynx.  If  the  trachea  is  opened,  the  edges  of  the  wound 
should  be  held  apart  with  tenacula,  the  head  dropped  over  the  end  of  a 
table  (Fig.  44),  any  clots  removed,  and  artificial  res])iration  practiced  by 
Sylvester's  method  (page  30).  In  the  closure  of  all  wounds  of  the  neck 
the  antiseptic  precautions  should  be  taken,  and  drainage  secured.  When 
the  pneumogastric,  hypoghjssal,  or  other  important  nerves  have  been 
divided,  the  ends  should  be  brought  together  by  a  delicate  silk  suture. 
It  is  also  advisable  to  unite  the  ends  of  divided  muscles  by  sutures. 
An  incised  wound  of  the  oesophagus  should  be  closed  immediately. 
Lacerated  wounds  of  this  tube  should  be  allowed  to  close  by  granulation. 
Difficulty  in  deglutition  follows  severe  wounds  f)f  the  throat,  not  infre- 
quently necessitating  the  introduction  of  liquid  food  through  the  tt'so- 
phageal  tube,  or  feeding  by  the  rectum. 

Punctured  wounds  of  the  neck  should  be  dressed  antiseptically,  and 
compression  employed  to  arrest  haemorrhage.  If  this  does  not  succeed, 
the  ligature  should  be  applied. 

Gunshot  wounds  should  be  treated  in  practically  the  same  manner. 
Missiles  of  small  caliber  deeply  lodged  should  be  left  alone,  since  they 
usually  become  encapsuled  and  remain  harmless.  When  superficial  and 
readily  detected,  they  slK)uld  be  extracted  by  the  forceps.  In  the  effort 
to  locate  a  bullet  it  is  always  important  to  place  the  parts  in  about  the 


THE  NECK.  445 

same  position  as  at  the  time  when  the  missile  penetrated.  If  this  is  not 
done,  the  muscles  and  fascia  become  displaced,  and  tlie  trade  of  the 
wound  obstructed.  Gimsliot  wounds  traversing  the  outer  lateral  and 
superficial  posterior  regions  of  the  neck  are  not,  as  a  rule,  dangerous.  If 
the  vertebral  column  is  involved,  tlie  prognosis  becomes  grave.  A  mis- 
sile traversing  the  tissues  of  the  neck  laterally,  and  in  front  of  the  ver- 
tebral column,  is  apt  to  intlict  fatal  injury. 

Abscess. — Abscess  of  the  neck  occurs  most  frequently  in  children,  and 
may  follow  an  injury,  or  result  from  an  idiopathic  inflammation  of  the 
tissues  of  this  region.  It  occurs  very  frequently  as  a  result  of  adenitis, 
or  periadenitis,  tonsillitis,  and  in  caries  of  the  upper  cervical  vertebrae, 
or  base  of  the  skull  (retro-pharyngeal  abscess).  It  may  also  follow  the 
lodgment  of  a  foreign  body  in  the  oesophagus.  Collections  of  pus  in  the 
upper  cervical  regions,  and  in  the  superficial  i)ortions  of  the  root  of  the 
neck,  tend  to  become  encapsuled,  or  may  open  iiltimately  through  the 
integument.  Retro-pharyngeal  abscess,  if  left  alone,  not  infrequently 
travels  downward  along  the  deeji  fascia  of  the  neck,  and  may  ojaen  into 
the  mediastinum. 

The  diagnosis  of  abscess  in  the  neck,  from  the  various  tumors  which  are 
found  in  this  region,  depends  upon  the  febrile  movement  pi-esent  in  ab- 
scess, the  acute  and  persistent  chai-acter  of  the  pain,  and  fluctuation.  The 
value  of  exploration,  with  an  aspirator-needle  large  enough  to  carry  pus, 
should  not  be  lost  sight  of  in  the  effort  to  arrive  at  a  positive  diagnosis. 

The  treatment  is  evacuation,  either  by  the  method  of  aspiration  and 
hyper-distention  already  given,  or  by  puncture  or  incision,  and  free  drain- 
age. When  the  abscess  is  situated  in  a  portion  of  the  neck  rich  in  ves- 
sels, it  should  be  opened  by  cutting  carefully  down  upon  it,  so  that  any 
haemorrhage  encountered  may  be  immediately  and  readily  controlled.  If 
a  puncture  is  determined  ujion,  the  knife  shoixld  be  introduced  in  the  part 
farthest  from  the  vessels,  and  along  the  aspirator-  or  exploring-needle  as  a 
guide.  As  soon  as  the  sac  is  entered  by  the  instrument  it  is  withdrawn 
and  a  dull-pointed  dressing-forceps,  tightly  closed,  is  carried  into  the  ab- 
scess, when,  by  forcible  separation  of  the  jaws,  the  puncture  is  enlarged. 

The  finger  may  now  be  introduced,  or,  if  this  can  not  be  done,  the 
forceps  will  indicate  the  size  and  most  dejiendent  portion  of  the  sac.  If 
the  first  ox)ening  has  not  been  made  at  the  lowest  part  of  the  abscess,  or 
is  not  so  situated  that  thorough  drainage  is  secured,  it  should  be  enlarged 
so  as  to  extend  this  far,  or  a  counter-opening  made  by  boring  through 
with  the  forceps  until  the  skin  is  distended  over  the  point  of  the  instru- 
ment, when  it  can  be  safely  incised.  Drainage  should  be  maintained, 
and  the  cavity  irrigated  with  l-to-3000  sublimate  solution. 

The  diagnosis  of  retro-pharyngeal  abscess  depends  upon  the  follow- 
ing symptoms:  Pain,  a  feeling  of  soreness  and  stiffness  in  the  neck, 
swelling,  with  protrusion  of  the  posterior  wall  of  the  pharynx  if  the  dis- 
ease is  high  up,  interference  with  deglutition  and  respiration.  In  the 
earlier  stages  all  of  these  symptoms  will  not  be  present,  but  as  soon  as 
this  dangerous  condition  is  suspected  an  effort  should  be  made  to  locate 
the  abscess  by  i^alpation  and  aspii'ation. 


446  A  TEXT-BOOK  OX  SURGERY. 

In  evacuating  the  pus  an  incision  should  lie  made  lu  the  pharynx,  as 
near  the  median  line  as  possible.  Wlien  a  large  quantity  of  liuid  is 
present  the  head  sliould  be  inclined  downward  as  the  incision  is  made, 
so  that  the  contents  of  the  abscess  may  not  gravitate  into  the  larynx. 
This  danger  may  be  obviated  by  partially  emptying  the  sac  by  the  aspi- 
rator before  the  incision  is  nuide.  When  the  sac  extends  low  down  the 
neck  it  should  be  entered  and  drained  from  below.  Deep  retro-pharyn- 
geal  abscess  may  be  reached,  as  a  rule,  by  the  incision  and  dissection  laid 
down  in  the  operation  of  oesophagotomy. 

Phlegmon  of  the  neck  demands  free  incision  in  all  cases,  when  such 
incision  does  not  encroach  upon  the  important  organs  of  this  region. 

Tumors  of  the  Neck — Solid  and  Cystic — Lymplioma. — Pathological 
changes  in  the  lymphatics  of  the  neck  account  for  the  large  majority  of 
swellings  in  this  region.  Lymphoma  of  the  neck  may  be  solid  or  cystic, 
benign  or  malignant. 

Tumors  of  the  cervical  glands  may  comprise  simple  lymphoma,  the 
result  of  hypertrophy  and  hyperplasia ;  tubercular  lymi)homa,  lympho- 
sarcoma and  lymijhangiectasis. 

Lymplioma  occurs  most  frequently  in  the  submaxillary  and  upper  ca- 
rotid triangle,  and  next  in  order  of  frequency  ak>ng  the  line  of  the  great 
vessels  beneath  the  mastoideus,  and  lastly  in  the  subclavian  region.  In 
some  instances  these  tumors  attain  enormous  proportions,  filling  in  the 
neck  to  the  level  of  the  lower  jaw  and  clavicle,  and,  if  not  removed,  pro- 
duce death  by  pressure  upon  the  respii-atory  apparatus  or  the  oesophagus. 

Fatty  tumors  are  apt  to  occur  upon  the  posterior  aspect  of  the  neck, 
and  occasionally  in  the  clavicular  region.  They  are  comparatively  rare 
in  the  anterior  and  upper  triangles. 

Cystic  Tumors. — Cysts  of  the  neck  are  congenital  and  acquired. 

Congenital  cysts  are  rare.  The  form  most  frequently  observed  is  that 
already  mentioned  as  a  dilatation  and  hypertrophy  of  the  lymphatic  ves- 
sels (lymphangiectasis).  They  are  usually  multilocular,  and  may  extend 
deeply  and,  at  times,  assume  enormous  jn-oportions. 

Acquired  cysts  are  seen  chiefly  along  the  line  of  the  mastoid  muscles, 
having  a  tendency  to  occur  in  the  neighborhood  of  the  parotid  gland, 
less  frequently  in  the  subclavian  triangle. 

Cysts  resulting  from  extravasations  of  blood  may  also  occur  here,  and 
occasionally  distention  of  the  bursse  in  the  thyro-hyoid  region  produces 
cystic  tumors. 

Thyroid  Body. — Hypertrophy  or  hyperplasia  of  this  organ  may  be 
partial  or  complete.  All,  or  a  part,  of  one  lateral  lobe  is  usually  af- 
fected ;  less  frequently  the  isthmus  is  alone  involved.  The  offshoots  of 
this  body  which  are  met  with  at  times  near  the  hyoid  bone,  near  the 
inner  edge  of  the  sterno-mastoid  muscle,  and  occasionally  dipping  down 
behind  the  oesophagus,  may  also  become  enlarged.  Goitre,  or  broncho- 
cele,  is  usually  endemic,  and  attacks  females  more  often  than  males.  No 
climate  or  condition  of  living  affords  a  positive  immunity  from  this  dis- 
ease, although  in  certain  localities,  as  in  the  valleys  of  Switzerland,  it  is 
frequently  met  with.    The  cause  of  goitre  is  unknow^n.    It  is  undoubtedly 


THE  NECK.  447 

prone  to  occur  in  those  whose  surroundings  are  damp  and  unwholesome, 
and  among  the  poorly  fed.  The  influence  of  heredity  is  recognized  in 
the  occurrence  of  this  disease  in  the  children  of  patients  affected  with 
bronchocele. 

A  goitre  may  be  solid  or  cystic.  In  solid  goitre  the  enlargement  may 
be  caused  by  a  general  hypertrophy  of  the  normal  elements  which  com- 
pose this  body,  or  some  of  these  elements  may  undergo  proliferation 
and  increase  at  the  expense  of  the  others.  When  the  tumor  is  hard  and 
tense,  it  is  called  fibrous  goitre,  and  in  this  form  the  chief  i^athological 
change  is  an  increase  in  the  connective-tissue  elements  of  the  stroma. 

In  cystic  goitre  the  tumor  is  caused  by  the  accumulation  of  a  dark- 
brown  fluid  within  the  substance  of  the  organ.  There  may  be  one  or 
more  separate  collections  of  fluid,  although  a  multilocular  arrangement 
is  most  common. 

The  diagnosis  of  goitre  is  not  difficult.  The  presence  of  a  tumor  in 
the  region  of  the  thyroid  body,  usually  unilateral,  occasionally  bilateral, 
moving  with  the  trachea  in  the  act  of  deglutition,  capable  of  very  percep- 
tible enlargement  during  coughing  or  any  prolonged  and  violent  expira- 
tory effort,  are  symptoms  which  point  quite  clearly  to  bronchocele.  As 
to  determining  the  character  of  the  tumor,  one  must  depend  upon  pal- 
pation in  great  part,  and  also  upon  exploration  with  the  aspirator.  Fi- 
brous goitre  is  dense,  hard,  very  slightly  elastic,  often  presenting  irregu- 
larities in  surface.  Cystic  bronchocele  is  round,  smooth,  elastic,  movable, 
and,  even  when  the  capsule  is  greatly  distended,  fluctuation  is  percepti- 
ble. The  use  of  the  exploring-needle,  and  the  withdrawal  of  a  portion 
of  the  fluid  contents  for  microscopical  examination,  is  important  in  diag- 
nosis. 

The  fluid  from  a  cystic  goitre  varies  in  color  from  amber  to  dark 
brown  and  almost  black.  Under  the  microscope  crystals  of  cholesterin, 
crenated  red  blood-corpuscles,  large  compound  granular  cells,  leuco- 
cytes, etc.,  are  seen.  The  characteristic  contents  of  Tiydatid  cysts  are 
easily  recognized  and  excluded.  Fibro-cystic,  or  mixed  goitres,  jiossess 
some  of  the  characteristics  of  both  the  foregoing  varieties.  The  feeling 
of  solidity  is  not  so  great  as  in  the  fibrous,  and  is  less  elastic  and  with 
a  less  appreciable  sense  of  fluctuation  than  in  cystic  bronchocele. 

Sarcoma  and  carcinoma  of  this  organ  are  hard,  solid  tumors  of  rapid 
development,  steadily  increasing  in  size,  and  in  their  growth  binding 
the  invaded  organ  to  the  integument,  muscles,  and  fascia  of  the  neck. 
Abscess  would  have  a  previous  liistory  of  inflammation,  pain,  and  febrile 
movement.  Aneurism  of  the  carotid  appears  usually  to  the  outer  side 
of  the  thyroid  region,  and  presents  the  symptoms  of  expansicm  with 
the  heart's  systole,  the  aneurismal  thrill  and  murmur,  all  of  which  symp- 
toms disappear  after  pressure  upon  the  artery  on  the  cardiac  side  of  the 
tumor. 

The  diagnosis  of  other  cervical  tumors  may  be  considered  here.  Tu- 
bercular lymphomata  are  recognized  by  their  anatomical  locations,  by 
their  slow  process  of  development,  together  with  the  personal  and  family 
history  of  the  individual. 


448  A  TEXT-BOOK  ON  SURGERY. 

In  many  instances  these  tumors  of  the  glands  remain  quiet  for  a 
period,  and,  responding  to  some  irritation,  an  adenitis  and  periade- 
nitis are  developed,  which  lajiidly  lead  to  the  formation  of  abscess. 
Tliey  are  found  most  frecpieiilly  along  the  lower  border  of  the  inferior 
maxilla,  in  the  lower  parotid  region,  along  the  under  surface  and  poste- 
rior Ixmler  of  the  sterno-mastoid  muscle,  and  in  the  subclavian  triangle. 

Metastatic  lymphoma,  secondary  to  epithelioma  or  other  malignant  dis- 
ease of  the  face,  will  be  recognized  by  the  history  of  the  case.  Lympho- 
sarcoma of  the  neck  is,  in  its  earlier  stages  of  development,  with  difliculty 
differentiated  from  simple  adenoma.  It  grows,  however,  with  much 
greater  rajndity,  and,  by  its  tendency  to  become  fixed  to  the  surround- 
ing tissues,  suggests  its  malignant  nature.  It  is  most  usually  located 
about  the  center  of  the  neck  and  beneath  the  sterno-mastoid  muscle. 

Treatment. — Cystic  goitre  does  not  yield  to  constitutional  measures. 
Solid  tumors  should  be  treated  by  the  administration  of  full  doses  of 
potassium  iodide.  If  marked  diminution  in  the  size  of  the  tumor  does 
not  follow  within  the  first  few  weeks  of  this  treatment  it  should  be  dis- 
continued. 

Brcmchocele,  either  solid  or  cystic,  which  is  small  in  size  and  not  per- 
ceptibly increasing,  does  not  demand  surgical  interference.  Such  tumors 
should  be  kept  under  observation,  and  if  at  any  time  there  is  a  marked 
increase  in  size  operative  interference  is  called  for,  before  the  mass  has 
assumed  such  proportions  that  its  removal  involves  considerable  danger 
to  life.  According  to  Kocher,  another  centra-indication  to  surgical  inter- 
ference is  the  presence  of  a  goitre  involving  the  entire  organ,  since — al- 
though the  operation  may  be  recovered  from — death  results  in  fi'om  one 
to  two  years,  from  the  development  of  a  strumous  condition  not  unlike 
that  known  as  myxoedenui.  Physiological  experiments  have  shown  that 
a  like  condition  results  from  the  total  extirpation  of  the  thyroid  body  in 
animals.  Under  no  circumstances,  therefore,  is  a  complete  removal  of 
this  body  justifiable.  One  side  and  the  isthmus  may  be  removed,  and  in 
extreme  cases  both  lobes  may  be  extirpated,  provided  the  isthmus  is  left 
undisturbed. 

Another  contra  indication  is  calcareous  degeneration  of  a  considerable 
portion  of  the  mass,  causing  a  condition  of  friability  in  the  vessels  which 
renders  their  deligation  unsafe. 

Operation  —  Cystic  Goitre. — Make  a  perpendicular  incision,  about 
three  inches  in  length,  over  the  center  of  the  tumor.  Divide  the  integu- 
ment, fascia,  and  intervening  muscles  down  to  the  sac.  Upon  approach- 
ing this,  the  dissection  should  be  carried  on  between  two  anatomical  for- 
ceps, lifting  only  a  thin  bit  of  tissue  at  each  grasp  of  the  instruments, 
and  looking  closely  for  any  vessels  which  may  run  upon  or  through  the 
anterior  wall  of  the  tumor.  When  the  wall  is  reached  it  should  be 
divided  in  the  same  manner,  and,  upon  the  escape  of  the  contents  through 
the  opening,  this  should  be  enlarged  by  introducing  the  dressing-forceps 
and  dilating.  The  opening  in  the  wall  should  be  about  one  inch  long. 
A  continuous  catgut  suture  should  be  carried  through  the  integument, 
stitching  this  to  the  edges  of  the  sac.     The  cyst  should  now  be  well  irri- 


THE  NECK.  449 

gated  with  l-to-5000  sublimate  solution,  and  rubber  drainage-tubes  intro- 
duced, one  into  the  deepest  and  another  in  the  upper  portion  of  the  sac. 
A  loose  sublimate  dressing  should  be  applied.  The  indications  for 
changing  the  dressing  are  haemorrhage,  rise  in  temperature  above  103° 
after  the  second  day,  and  for  purposes  of  cleanliness.  In  two  of  my  cases 
in  which  larger  cysts  were  evacuated  there  was  consideraljle  febrile  move- 
ment for  the  first  week  after  the  operation.  As  the  cyst  becomes  filled 
with  granulation-tissue  the  tubes  should  be  gradually  shortened. 

In  the  removal  of  a  solid  goitre  a  crucial  incision  is  preferable.  This 
should  be  very  free,  in  order  to  give  a  full  view  of  the  wound.  The 
dissection  should  expose  the  entire  anterior  surface  of  the  mass  before 
attempting  to  get  beneath  it  at  any  point.  Care  must  be  taken  not  to 
tear  or  incise  the  substance  of  the  tumor,  since  it  bleeds  profusely,  and 
is  often  so  friable  that  it  will  not  hold  a  ligatui'e.  Whenever  a  vessel  is 
seen  in  the  track  of  the  dissection,  it  should  be  seized  in  two  places  with 
forceps  (the  narrow-Jawed  instrument,  Fig.  82,  is  preferable),  divided  be- 
tween them,  and  each  end  tied  with  stout  catgut. 

In  lifting  the  tumor  the  operator  should  Avork  along  the  outer  side, 
and  pass  under  the  mass  fi'om  this  aspect.  In  this  way  the  superior  and 
inferior  thyroid  vessels  may  be  ligatured  in  the  earlier  stages  of  the 
operation,  and  the  chief  source  of  bleeding  controlled.  The  presence  of 
the  recurrent  laryngeal  nerves,  as  they  pass  upward  on  either  side,  in  the 
space  between  the  trachea  and  oesophagus,  should  not  be  forgotten.  It 
is  not  always  possible  to  avoid  them,  but  by  keeping  close  to  the  capsule 
of  the  tumor  the  least  risk  will  be  incurred.  The  veins  passing  into  the 
mass  are  at  times  of  great  size,  and  the  walls  of  those  in  the  tumor  are  in 
some  cases  very  friable,  causing  much  annoyance  and  delay,  in  repeatedly 
breaking  down  under  the  ligature  and  recurring  hsemorrhage.  In  one  of 
my  cases  the  internal  jugular  vein  was  involved  in  the  mass  to  such  an 
extent  that  it  was  necessary  to  tie  this  vessel  above  and  below,  and  divide 
it.  When  all  of  the  tumor  is  free,  except  the  isthmus,  this  should  be 
surrounded  with  a  small  elastic  ligature,  and  divided.  The  edges  of  the 
wound  are  now  closed  with  catgut,  the  drainage-tube  and  rubber  ligature 
brought  out  at  the  most  dependent  portion  of  the  incision,  and  a  subli- 
mate dressing  applied.  The  ligature  comes  away  by  drawing  upon  it 
about  the  eighth  day. 

The  prognosis  from  this  operation  is  favorable  in  the  large  majority 
of  cases.  It  only  becomes  grave  in  the  larger  tumors,  and  the  chief  ele- 
ment of  gravity  here  is  the  exhausted  condition  of  the  patient,  resulting 
from  pressure  of  the  mass.  It  must,  however,  be  classed  among  the  more 
formidable  operations. 

Hydatid  cysts  may  occasionally  be  met  with  in  this  organ.  They 
should  be  treated  by  incision  and  drainage,  or  by  aspiration  and  disten- 
tion of  the  sac,  with  l-to-20  carbolic-acid  solution,  withdrawing  the  solu- 
tion and  applying  compression. 

Carcinoma  and  sarcoma  of  this  body  are  treated  in  the  same  manner 
as  solid  goitre.  When  their  removal  is  possible,  the  dissection  should  be 
carried  well  into  the  healthy  tissues  beyond  the  neoplasm. 

29 


450  A  TEXT-BOOK  ON  SURGERY. 


The  Larynx  axd  Trachea. 

The  operations  upon  these  organs  in  the  neck  are  thyrotomy,  laryn- 
gotomy,  larym/o-tracheotomy,  tracheotomy,  and  exsection  of  the  larynx. 
T/iyrotomyis  indicated  in  the  removal  of  neoplasms  or  foreign  bodies 
from  the  larynx,  which  can  not  be  reached  through  the  month  by  the  aid 
of  the  laryngoscope  and  forceps  or  snare.  The  patient  should  be  placed 
upon  the  table,  with  the  head  well  depressed.  Make  a  perpendicular 
incision  from  near  the  center  of  the  hyoid  bone,  exactly  in  the  median 
line  of  the  pomum  Adami,  as  far  down  as  the  cricoid  cartilage.  The 
bleeding  is  thoroughly  arrested,  and  the  two  wings  of  the  thyroid  carti- 
lage divided  exactly  in  the  angle  of  union.  This  should  be  done  with 
great  care,  in  order  to  avoid  wounding  the  vocal  bands,  which  are  at- 
tached on  either  side  of  the  median  line,  in  front.  If  at  this  stage  of  the 
operation  a  tenaculum  is  inserted,  on  either  side,  the  alje  may  be  drawn 
apart,  freely  exposing  the  interior  of  the  larynx.  In  closing  the  wound 
the  cartilages  are  not  included  in  the  sutures,  it  being  sufficient  to  bring 
the  edges  of  the  skin  together. 

In  larynr/otomy  the  opening  is  made  through  the  crico-thyroid  mem- 
brane. It  is  indicated  in  oedema  of  the  glottis,  obstruction  of  the  larynx 
by  new  growths,  foreign  bodies,  and  excejjtionally  in  rapid  inflammatory 
swelling  of  the  tonsils  or  jjharynx,  Vith  occlusion  of  the  larynx. 

AVhen  the  emergency  demands  it,  rapid  laryngotomy  may  be  per- 
formed as  follows :  Make  a  single  incision  from  the  notch  in  the  upper 
margin  of  the  thyroid  cartilage,  in  the  median  line,  to  the  lower  edge  of 
the  cricoid  ring,  then  turn  the  knife-edge  upward  and  thrust  the  point 
through  the  crico-thyroid  membrane.  A  hook  should  now  be  quickly 
inserted  on  either  side,  and  the  edges  of  the  wound  separated.  Traction 
not  only  opens  the  wound  in  the  membrane  to  admit  the  air  more  freely, 
but  it  also  arrests  the  bleeding.  When  tenacula  can  not  be  had,  a  fair 
substitute  may  be  extemporized  from  wire,  or  the  ordinary  metal  hair- 
pin. The  opening  in  the  membrane  may  be  enlarged  by  a  transverse 
incision  when  necessary. 

When  expedition  is  not  urgent,  the  bleeding  from  the  wound  in  the 

integument  should  be  arrested  before  the  open- 
ing into  the  larynx  is  made. 

If  it  is  necessary  to  keep  the  wound  open, 
a  silver  trachea-canula  (Fig.  516)  should  be  in- 
serted. This  instrument  is  secured  by  a  tape 
tied  around  the  neck.  AVhen  it  becomes  ob- 
structed, the  inner  canula  shovdd  be  withdrawn, 
cleansed,  and  reinserted,  and,  if  necessary,  the 
larger  tube  remaining  in  the  larvnx  should  be 

Fig.  516. — Double  trachea-tube,         ,  ,      ,  ..       -ii,  n  i  u     '  Tfv 

silver,  plain.  brushed  out  With  a  small  brush  or  mop.     V\  hen 

this  instrument  is  worn  it  should  be  carefuUy 
watched,  as  long  as  any  danger  of  its  becoming  obstructed  exists.  It 
may  be  worn  indefinitely  in  cases  of  permanent  laryngeal  steno.sis. 


THE   LARYNX  AND  TRACHEA. 


451 


Laryngotomy  loltlwut  a  Tube. — When  a  canula  is  not  at  hand,  a 
needle,  armed  with  fine,  strong  silk,  should  be  passed,  on  either  side, 
through  the  integument  and  cricoid  membrane,  brought  out  through  the 
opening  in  the  larynx,  and  the  suture  tied.  It  is  best  to  employ  two 
sutures  in  each  side  of  the  wound.  These  may  be  tied  behind  the  neck, 
or  attached  to  bits  of  adhesive  plaster  and  fastened  to  the  integument,  so 
as  to  keep  the  wound  open.  A  strip  of  plaster  should  be  laid  on  each 
side  of  the  wound,  to  prevent  the  thread  from  cutting  into  the  integu- 
ment. 

Laryngo-tracTieotomy  (an  operation  rarely  performed)  consists  in 
extending  the  incision  of  laryngotomy  through  the  cricoid  cartilage,  and 
the  upper  one  or  two  rings  of  the  trachea. 

TracTieotomy  is  more  frequently  done  than  either  of  the  operations 
just  given.  The  trachea  may  be  opened  (1)  above  the  isthmus  of  the 
thyroid  body,  the  upper  three  or  four  rings  being  divided ;  (2)  the 
isthmus  may  be  tied  with  a  double  ligature,  divided,  and  the  trachea 
opened  beneath  it ;  (3)  the  opening  into  the  tube  may  be  altogether  be- 
low the  isthmus. 

It  will  rarely  be  found  necessary  to  divide  the  isthmus.     The  opera- 
tion above  the  isthmus  is  simpler,  and  should  be  preferred  in  all  cases 
where  the  obstruction  is  in  the  larynx.     For  the  removal  of  a  foreign 
body  lodged  in  the  bifurcation  of  the  trachea,  or  in  either 
bronchus,  the  lower  procedure  should  be  adopted.     This  op- 
eration should  also  be  preferred  in  diphtheritic  croup  when 
all  other  measures  have  failed.     The  results  achieved  with 
the  laryngeal  tube  of  Dr.  O'Dwyer,  of  New  York,  justifies  a 
faithful  trial  with  this  instrument  before  resorting  to  the  for- 
midable operation  of  tracheotomy  in  diphtheritic  croup. 

Dr.  O'Dwyer's  directions  are  as  follows :  The  tubes  are 
of  various  sizes,  and  are  constructed  on  a  scale  (Fig.  517) 
somewhat  like  the  urethral  sounds.  No.  1  is  intended  for  a 
child  eighteen  months  old,  or  less  ;  No.  2,  betv>-een  eighteen 
months  and  three  years  ;  No.  3,  for  the  fourth  year ;  No.  4, 
for  the  fifth  year,  and  so  on. 

When  the  proper  tube  is  selected  for  the  case  to  be  oper- 
ated on,  a  fine  silk  thread  is  passed  through  the  small  hole 
near  its  anterior  angle,  and  left  long  enough  to  hang  out  of 
the  mouth,  its  object  being  to  remove  the  tube  should  it  be 
found  to  have  passed  into  the  ti'sophagus  instead  of  the 
larynx.  The  obturator  is  then  screwed  tightly  to  the  intro- 
ducing instrument,  to  prevent  the  possibility  of  its  rotating 
wdiile  being  inserted,  and  passed  into  the  tube. 

The  child  is  held  upright  on  the  nurse's  lap,  witli  its  arms  secured  by 
the  sides  or  behind  the  back.  An  assistant  holds  the  head,  which  he 
inclines  backward  at  the  proper  time,  while  the  operator,  seated  in  front, 
inserts  the  gag  (Fig.  518)  well  back  between  the  teeth,  in  the  left  angle 
of  the  mouth,  and  opens  it  as  widely  as  possible,  without  using  undue 
force.     He  then  inserts  the  index-finger  of  the  left  hand,  which  serves  to 


&TlEMANNi:o. 

8  -12  — 
3-4.— I 


Fio.  517. 
Scale. 


452 


A  TEXT-BOOK   ON   SURGERY. 


elevate  the  epiglottis  and  guide  the  tube  into  the  larynx.     The  handle  of 

the  introducing  instrument  (Fig.  619),  held  close  to  the  patient's  chest 

in  the  beginning  of  the  ojieration,  is 
rapidly  elevated  as  the  glottis  is  ap- 
proached, and  the  tube  pushed  down- 
ward without  using  natch  force.  It 
is  tlieu  detached,  and  the  obturator 
quickly  removed.  The  joint  in  the 
shank  of  the  obturator  is  for  the  pur- 
pose of  facilitating  this  part  of  the 

operation.     I^est  the  tube  should  also  be  withdrawn,  it  is  necessary  to 

keep  the  finger  in  contact  with  it. 


Fio.  519. — Introducer. 

When  it  is  ascertained  with  certainty  that  the  canula 
is  in  the  larynx  (and  for  this  purpose  it  is  better  to  wait 
Tintil   the  child  coughs,  or  until  it  is  evident  that  the 
dyspnoea  is  relieved),  the  finger  is  again  placed  in  con- 
Tubes,         tact  with  it  and  the  thread  removed. 

It  is  important  that  the  attempt  at  introduction  be 
made  quickly,  as  respiiution  is  practically  suspended  from  the  time  that 
the  finger  enters  the  larynx  until  the  obturator  is  removed.  It  is,  there- 
fore, under  the  circumstances  much  safer  to  make  several  abortive  at- 
tempts than  one  prolonged  effort,  even  if  successful. 

The  removal  of  the  canula  is  a  more  difficult  operation  than  its  intro- 
duction, owing  to  the  fact  that  the  aperture  of  the  tube  into  which  the 


extracting  instrument  (Fig.  520)  has  to  be  inserted  is  so 
much  smaller  than  that  of  the  larynx.  At  the  same  time 
more  deliberation  can  be  used,  and  an  anfesthetic,  which  is 
never  necessary  for  the  introduction,  can  be  given  if  required. 
There  is  no  danger  whatever  of  these  tubes  slipping  through  into  the 

trachea,  even  if  used  on  older  children  than  those  for  which  they  are 

intended. 

Some  practice  on  the  cadaver  is  a  very  necessary  preliminary  to  using 

them  on  the  living  subject.    It  is  well  also  to  bear  in  mind  that  it  is  much 

more  difficult  to  reach  the  larynx  in  the  dead  than  in  the  living. 


High  Operation. — Place  the  patient  on  the  back,  in  such  a  position 
that  the  head  falls  well  over  the  end  of  the  table.     If  an  anaesthetic  is 


THE  LARYNX,   TRACHEA,   AND   BRONCHI.  453 

not  given,  one  assistant  should  hold  the  extremities  immovable,  while  a 
second  steadies  the  head.  The  operator  should  stand  to  the  patient's 
right,  facing  the  light.  It  is  important  tliat  the  head  he  held  so  that 
the  nose  and  sj-mphysis  menti  will  be  directly  in  line  witli  the  inter- 
clavicular notch  and  umbilicus,  for  if  this  precaution  is  not  taken  the 
trachea  may  be  displaced,  an  accident  which  might  lead  to  great  annoy- 
ance, especially  in  children,  in  whom  this  tube  is  always  very  small. 
The  incision  should  be  exactly  in  the  median  line,  commencing  at  the 
center  of  the  thyroid  cartilage  and  extending  downward  one  inch  and  a 
half,  or  more  if  necessary.  The  edges  of  the  wound  should  be  separated 
by  retractors,  and  the  incision  continued  down  to  the  tube.  All  bleeding 
should  be  arrested  by  the  forceps  and  ligature  before  the  trachea  is 
opened,  for  fear  of  suffocation  from  the  entrance  of  blood. 

In  some  subjects  it  will  be  found  that  the  isthmus  of  the  thyroid  body 
is  situated  so  high  that  an  opening  sufficiently  long  can  not  be  made 
without  displacing  it  downward.  This  may  be  done  by  dividing  with 
the  curved  scissors  the  muscular  and  ligamentous  bands  which  are  at- 
tached to  the  isthmus  below,  and  the  hyoid  bone  and  thyroid  cartilage 
above.  This  section  should  be  made  on  either  side  of  the  incision,  oppo- 
site the  first  ring  of  the  trachea.  After  all  bleeding  has  ceased,  the  knife 
should  be  carried  into  the  trachea  with  the  edge  directed  upward,  and 
the  two  or  three  upper  rings  divided. 

Low  Operation. — The  incision  through  the  integument  extends  from 
the  cricoid  cartilage  to  the  level  of  the  inter-clavicular  notch.  Separate 
the  sterno-thyroid  muscles  in  the  median  line,  and  carry  the  dissection 
carefully  down  to  the  trachea,  avoiding  the  istlimus  of  the  thyroid  body 
and  the  inferior  thyroid  vein,  a  branch  of  which  is  in  front  of  this  tube. 
The  anterior  jugular  vein  occasionally  is  in  the  median  line.  Any  of 
these  vessels  coming  within  the  line  of  incision  should  be  secured  with 
a  double  ligature  before  being  divided.  The  trachea  will  be  found  deep- 
ly situated,  and  should  be  incised  through  four  or  live  rings,  in  the  same 
manner  as  advised  in  the  preceding  operation.  If  a  trachea-tube  is  not  at 
hand,  the  operation  may  be  completed,  as  advised  in  laryngotomy,  with- 
out a  tube. 

Foreign  Bodies  in  the  Larynx,  Tr.\chea,  and  Bronchi. 

Foreign  bodies  in  the  respiratory  tract  are,  in  almost  all  instances, 
introduced  by  way  of  the  larynx,  into  which  they  may  fall  by  gravity 
or  be  drawn  in  by  the  suction-force  of  the  inspiratory  effort.  Occasion- 
ally they  enter  directly  from  without,  as  in  stab-  or  gunshot  wounds,  or 
may  make  their  way  in  from  the  oesophagus  by  perforation  or  from  the 
rupture  of  an  aneurism  or  abscess.  Pieces  of  coin,  buttons,  teeth,  seeds, 
threads,  pins,  blow-gun  darts,  shot,  particles  of  food,  etc.,  are  among  the 
most  frequent  substances  lodged  in  the  air-passages.  A  foreign  body 
may  lodge  just  behind  the  epiglottis,  across  the  rima  glottidis,  in  the 
ventricle  between  the  true  and  false  bands,  between  the  vocal  cords,  or, 
passing  these,  it  may  descend  into  the  trachea  or  bronchus.     If  it  be  a 


454  A  TEXT-BOOK  ON  SURGERY. 

solid  and  smooth  body,  it  will  pass  into  tlie  bronchus  and  continue  to 
descend  until  the  smaller  diameter  of  the  tube  arrests  its  progress.  Any 
substance  with  projectini!;,  sharp  e(l<res,  or  long  and  pointed,  as  a  pin  or 
tish-bone,  may  become  lodged  across  the  windpipe  at  any  point. 

The  symptoms  of  foreign  body  in  the  air- passages  are  immediate 
and  remote.  Strangulation,  cough,  and  cyanosis  immediately  after  the 
escape  of  any  substance  backward  from  the  mouth  or  nose,  or  matter 
which  has  been  regurgitated  from  the  stomach,  always  suggest  the  en- 
trance of  foreign  matter  into  the  larynx  or  trachea.  In  some  cases  death 
ensues  almost  instantly  from  asphyxia.  In  others  the  symptoms  of 
strangulation  last  for  a  few  moments  and  then  disappear,  leading  the 
patient  or  attendant  to  believe  that  the  foreign  body  has  been  coughed 
out  or  swallowed.  The  momentary  cyanosis  and  strangulation  are  caused 
by  spasm  of  the  laryngeal  muscles,  induced  by  direct  irritation  from  the 
foreign  body.  As  soon  as  these  relax  a  forcible  inspiratory  effort  may 
carry  the  substance  downward  to  the  trachea  or  bronc^hus,  or  the  expira- 
tory cough  may  have  discharged  it  into  the  mouth.  In  any  event,  the 
symptoms  of  asphyxia  disappear  unless  the  offending  substance  is  so 
large  that,  even  when  sucked  into  the  trachea,  it  completely  occludes  this 
tube.  The  remote  symptoms  of  foreign  bodies  in  the  air-jiassages  are 
chiefly  inflammatory.  Traumatic  trachitis,  bronchitis,  pneumonia,  gan- 
grene, and  abscess  may  ensue.  Abscess  and  gangrene  are  rare.  Bron- 
chitis is  inevitable,  and  localized  or  lobar  pneumonia  is  not  infrequent. 

The  diagnosis  may  be  determined  by  inspection,  palpation  (either 
direct  or  intermediate),  and  by  auscultation,  together  with  a  due  regard 
for  the  sensations  experienced  by  the  patient.  Inspection  is  only  possible 
with  the  laryngoscope.  Direct  palpation  is  only  possible  when  the  sub- 
stance is  lodged  in  the  larynx,  since  the  tip  of  the  finger  can  not  be  car- 
ried beyond  this  point. 

Auscultation  is  of  great  aid  to  diagnosis,  especially  when  the  body 
has  passed  deep  into  the  respiratory  tract.  Diminution  or  absence  of 
the  normal  vesicular  murmur  over  one  entire  lung  indi(;ates  the  partial 
or  complete  occlusion  of  one  primary  bronchus  by  the  foreign  body.  If 
this  interference  is  limited  to  only  a  portion  of  the  lung,  the  indication 
is  that  the  body  has  passed  into  one  of  the  subdivisions  of  the  bronchus. 

The  compensatory  increase  of  the  normal  vesicular  resjnration  in  the 
opposite  lung  will  be  proportioned  to  the  interference  with  the  function 
of  the  affected  side.  When  a  narrow  body  becomes  lodged  in  the  trachea 
or  bronchus,  its  presence  is  indicated  by  a  sibilant  or  hissing  sound, 
heard  with  greatest  intensity  over  the  point  of  lodgment,  and  carried 
upward  and  downward  with  the  expiratory  or  inspiratory  movement. 

The  presence  of  pain  persisting  in  a  given  locality  points  to  the  seat 
of  lodgment  of  the  foreign  substance.  Persistent  spasm  of  the  larynx 
until  tolerance  is  acquired  suggests  lodgment  in  the  ventricle  of  this 
organ. 

Treatment. — The  immediate  indication  is  the  prevention  of  fatal  as- 
phyxia, and  this  may  require  rapid  laryngotomy  or  tracheotomy,  and, 
in  exceptional  instances,  the  resuscitation  of  the  patient  by  the  method 


THE   LARYNX,   TRACHEA,    AND    BRONCHI.  455 

of  Sylvester  (page  30).  As  soon  as  this  danger  is  obviated,  the  removal 
of  the  foreign  body  may  be  undertaken.  It  is  well  to  remember  that  in 
a  few  instances  synii^toms  of  asphyxia  have  been  produced  from  the 
epiglottis  having  been  drawn  into  the  rima  glottidis  by  a  powerful  in- 
spiratory effort. 

When  fatal  asi)hyxia  is  not  threatened,  no  immediate  operation  is  in- 
dicated. The  patient  should  be  turned  head  downward  and  violently 
shaken,  and  at  the  same  time  made  to  cough  or  sneeze.  If  the  substance 
is  smooth  or  heavy,  it  may  be  dislodged  and  expelled  in  this  manner. 

If  this  procedure  is  unsuccessful,  the  question  of  operative  interfer- 
ence should  be  considered.  If  the  body  can  be  located  in  the  larynx,  it 
can  readily  be  removed  by  the  operation  of  thyrotomy  if  the  patient  is 
a  child,  or  by  laryngotomy  and  the  introduction  of  the  little  finger  into 
the  organ  through  the  wound  in  the  adult,  pushing  the  offending  sub- 
stance upward  into  the  pharynx.  Either  of  these  procedures  is  prac- 
tically free  from  danger.  When  the  foreign  body  has  passed  into  the 
trachea  or  bronchi,  the  necessity  for  operative  interference  will  depend 
U])on  its  size,  shape,  and  location.  If  it  is  small,  and  produces  no  marked 
disturbance  of  respiration,  and  is  deeply  lodged,  no  eifort  should  be 
made  to  remove  it,  for  the  following  reasons  :  When  small,  it  is  not  apt 
to  inflict  serious  damage  ;  the  tracheotomy  and  the  introducti(m  of  in- 
struments into  the  respiratory  tract  are  dangerous  operations ;  lastly,  the 
uncertainty  of  finding  or  dislodging  a  small  body  should  be  taken  into 
consideration. 

When,  however,  the  character  of  the  foreign  body  is  such  that  its 
presence  is  a  source  of  great  danger  to  the  patient,  and  it  can  not  be  re- 
moved without  operation,  surgical  interference  is  demanded.     The  posi- 
tion for  the  patient  is  the 
same  as  for   tracheotomy, 
and  this  operation  should 
be   done   as   low   down   as 
possible.      When   the    tra- 
chea   is    opened,     the    little  Fm.  521.— Forceps  for  removing  foreign  bodies  I 
/.                   1111                    •     1  Irom  tlie  cractioa  anJ  bronciiu 

nnger  should  be  carried 
downward  to  the  bifurca- 
tion in  the  hope  of  locating  the  body,  and,  if  discovered,  it  should  be 
grasped  with  a  pair  of  forcejjs  and  removed.  If  it  is  not  encountered 
below,  the  upper  portion  of  the  tube  should  be  examined  in  the  same 
way.  If  it  can  not  be  reached  by  the  finger,  the  angular  alligator-forceps 
(P"'ig.  521)  should  be  carried  into  the  bronchial  tubes,  carefully  regarding 
any  arrest  in  the  progress  of  the  instrument. 

A  solid  or  large  body  may  be  felt  and  seized  without  great  difficulty. 
A  small,  light  substance  may  be  touched  without  any  sense  of  resistance 
to  the  hand  of  the  operator.  If  it  can  not  be  recognized,  the  point  of 
the  instrument  should  be  carried  into  the  bronchus  in  which  the  body  is 
located,  the  jaws  separated,  and,  while  open,  carried  aboixt  half  an  inch 
further  in,  and  then  closed  and  withdrawn  in  order  to  see  if  the  object 
has  been  grasped.     This  manceuvre  is  repeated  several  times  until  the 


456 


A  TEXT-BOOK   ON  SURGERY. 


whole  length  of  the  bronchus  has  been  searched.  If  the  foreign  body  is 
not  found,  it  will  be  judicious  to  search  in  the  opposite  bronchus,  for  it 
is  possible  for  it  to  have  been  dislodged  in  the  course  of  the  exploration, 
and  carried  by  the  respiratory  efl'(jrt  into  the  trachea  and  down  into  the 
other  tube.  If  proper  forceps  can  not  be  obtained,  a  loop  of  silver  wire 
may  be  used. 

The  exploration  of  the  trachea  should  be  done  with  great  care  not  to 
inflict  unnecessary  violence  upon  the  mucous  membrane.  The  search 
should  not  be  prolonged  more  than  from  thirty  minutes  to  one  hour. 

If  the  body  is  removed,  the  wound  may  be  left  to  heal  by  gianidation, 
simply  closing  it  with  adhesive  strips,  or,  if  the  patient  has  borne  the 
anajsthetic  well,  it  will  be  better  to  stitch  the  trachea  with  catgut,  and 
the  edges  of  the  wound  separately  with  the  same  substance.  If  the  object 
ia  not  found,  the  tracheal  wound  should  be  kept  open  by  inserting  a  large 
trachea-tube,  or  by  sewing  the  tracheal  rings  to  the  edges  of  the  divided 
integument  and  keeping  the  wound  open  by  tying  the  strings  behind  the 
neck. 

Figs.  522  and  523  exactly  represent  an  air-gun  dart  which  was  lodged 
in  the  right  bronchus  of  a  boy  twelve  years  old,  who  came  under  my 

care  in  1884.*  In  the  act  of  tilling 
his  lungs  to  project  the  dart  from  the 
gun  it  was  carried  into  the  trachea. 
Spasm  of  the  laryngeal  muscles  fol- 
lowed for  a  few  moments,  with  marked 
cyanosis.  After  this  there  were  no 
symptoms  of  disturbance  beyond  a 
slight  cough.  I  performed  tracheot- 
omy at  the  lowest  point  jiossible,  dis- 
lodged the  body  by  forceps  carried 
into  the  bronchus,  when  it  was  eject- 
ed during  a  violent  paroxysm  of 
The  wound   was   left   to 


Fio.  622.— Dart, 
an  it  oxirne  trom 
the  bronchus. 


Fio.  .•i2.3.— The  same, 
before  it  entered. 


coughing. 


close  by  granulation. 

Lnryitgednvni,  or  exsecticm  of  the  larynx,  although  a  fonuidable 
operation,  is,  under  certain  conditions,  justifiable.  It  may  be  i)artial  or 
complete.  According  to  Cohen's  excellent  article,t  complete  laryngec- 
tomy has  been  performed  ninety-one  times.  The  gravity  of  the  procedure 
may  be  estimated  from  the  fact  that  over  one  tliird  of  all  the  cases  died 
within  eight  days  of  the  operation. 

The  conditions  which  justify  the  operation  are,  the  invasion  of  this 
organ  by  malignant  neoplasm,  and,  in  rare  instances,  destructive  chon- 
dritis, with  infiltration  and  threatened  occlusion  of  the  respiratoiy  tract. 
If,  after  a  careful  study  of  the  case,  the  surgeon  is  convinced  that  there 
is  a  fair  probability  of  relief  from  pain  and  prolongation  of  life  by  the 
removal  of  the  diseased  structures,  greater  than  he  would  be  likely  to 


*  '■  New  York  Medical  Journal,"  November,  1884,  p.  487. 

t  Ashhurst's  "  Encyclopsedia  of  Surgery,"  vol.  v.     William  Wood  &  Co.,  New  York. 


THE  LARYNX,  TRACHEA,  AND  BRONCHI. 


457 


Fig.  524. — Trendelenburg's  trachea-tampon,  with  inhaling-apparatos  attached. 


obtain  by  the  palliative  operation  of  tracheotomy,  he  is  justified  in  ad- 
vising the  operation.  When  the  tissues  about  the  larynx  are  widely 
infiltrated  with  the  malignant  neoplasm,  the  operation  is  not  justifiable. 

It  is  performed  as  follows  :  The  patient  is  anesthetized  with  ether,  by 
the  mouth,  and,  when  once  fully  anaesthetized,  the  narcosis  should  be 
continued  by  the  rectum.  The  first  step  is  to  reach  the  trachea  at  a  jjoint 
sufficiently  low  to  be  well  out  of  the  diseased  zone.  An 
incision  is  made  as  in  tracheotomy,  and  a  Trendelen- 
burg's tube  (Fig.  524)  is  introduced.  The  end  of  this 
tube,  which  is  car- 
ried into  the  tra- 
chea, is  surround- 
ed by  a  rubber  bal- 
loon, which,  after 
its  introduction,  is 
inflated,  thus  com- 
pletely tamponing 
the  trachea  and 
preventing  the  es- 
cape of  blood  into  the  bronchi.  The  attachment  for  inhalation  of  ether 
may  be  used  if  needed.  The  oi'gan  is  best  exposed  by  a  crucial  incision, 
and  all  bleeding  should  be  arrested  as  the  operation  proceeds.  It  is  best 
to  seize  all  vessels  between  two  forceps,  divide  and  tie  them  as  directed 
in  the  operation  for  the  removal  of  goitre. 

A  trachea-tube  should  be  inserted  after  the  exsection  is  completed. 
Alimentation  is  carried  on  through  an  oesophageal  tube,  or  bj^  introduc- 
tion into  the  rectum. 

Partial  laryngectomy  is  performed  in  the  same  general  way  as  the 
preceding  operation. 

Neoplasms  of  the  Larynx  and.  Trachea. — Almost  every  form  of  new 
growth  has  been  removed  from  the  larynx.  No  portion  of  the  organ  is 
exempt.  The  symptoms  are  referable  to  the  location  of  the  neoplasm 
and  to  its  size,  and  in  a  certain  sense  to  its  shape.  Those  situated  upon 
the  vocal  bands  are  first  noticed,  on  account  of  interference  with  the 
voice.  A  neoplasm  may  develop  in  the  ventricle,  and  not  be  noticed 
until  it  encroaches  upon  the  cords.  Dyspnoea  occurs  earlier  when  the 
tumor  is  situated  iipon  the  rima  glottidis. 

Cough  is  not  a  i)rominent  sjTuptom,  for  the  reason  that  the  slow  and 
progressive  development  of  the  neoplasm  gradually  accustoms  the  larynx 
to  its  presence.  Spasmodic  cough  does,  however,  occur  in  i^edunculated 
growths,  which  are  moved  to  and  fro  as  the  air  rushes  in  and  out  of  the 
larynx. 

The  diagnosifi  may  be  made  from  the  symptoms  detailed,  but  chiefly 
b}'  palpation  and  the  laryngoscope.  The  location  is  simple,  but  the  dif- 
ferentiation as  to  the  character  of  the  growth  is  at  times  difficult.  Papil- 
lomata  are  most  frequently  met  with,  and  papilloma  in  the  larynx  pos- 
sesses the  same  general  properties  observed  in  these  growths  in  more 
exposed   quarters.      They  are   most   commonly  found  upon   the   vocal 


458  A  TEXT-BOOK  ON  SURGERY. 

bands.  The  tumor  may  appear  in  the  mirror  as  a  single  wart-like  fun- 
gus, or  pinkish-gray  tuft  upon  the  cords  or  laryngeal  wall,  or  there  may 
be  several  which  fill  a  great  part  of  the  o])pning.  The  tibroid  laryngeal 
polypi  {Jlbruinnta)  are  chiefly  pyriiV)rm,  pedunculated,  and  smooth,  in 
location  and  color  resembling  the  papillomata. 

Enchondroiiiala  of  the  larynx,  less  frecpiently  observed  than  the  two 
preceding  neoplasms,  are  devel()j)ed  from  the  cartilage  ijrojjer  of  the 
larynx.  They  are  usually  seen  in  the  vicinity  of  the  crico-arytenoid 
articulation.  Cystir  tumors  are  rare.  Occlusion  of  the  duct  of  the  sac- 
culiis  laryngls  will  lead  to  the  apjjearance  of  a  tumor  in  the  ventricle, 
between  the  true  and  false  bands.  Other  cysts  may  result  from  sim])le 
follicular  occlusion.  Telangiectasis,  or  angioma.,  is  a  still  rarer  form  of 
laryngeal  tumor.  Carcinoma  {epithelioma)  is,  unfortunately,  not  a  rare 
disease  of  this  organ.  Sarcoma  is  very  rarely  met  with.  Epithelioma  of 
the  larynx,  in  common  with  all  malignant  (as  well  as  benign)  neoplasms, 
occtirs  chiefly  at  the  upper  portions  of  the  organ. 

The  treatment  of  all  forms  of  benign  tumors  of  the  larynx  is  their 
removal  with  the  knife,  scissors,  the  snare,  or  caustics.  Removal  of 
malignant  growths,  to  an  extent  sufficient  to  prevent  recurrence,  without 
a  total  or  partial  laryngectomy,  is  rarely  possible.  Benign  growths, 
especially  the  smaller  new  formations,  may  be  removed  best  by  chromic- 
acid  crystals  directly  apj^lied,  at  frequent  sittings.  A  small  pellet  of 
cotton  is  attached  to  the  end  of  the  applicator,  and  a  particle  of  chromic 
acid,  of  convenient  size,  is  picked  up  on  this  and  carried  down  to  the 
tumor.  The  crystals  adhere  to  the  lint  until  they  come  in  contact  with  a 
moist  surface.  In  carrying  the  instrument  through  the  mouth,  care  must 
be  taken  to  avoid  touching  the  mucous  surfaces.  Epithelioma,  in  its 
early  stages  of  development,  may  be  successfully  destroyed  by  this 
escharotic.  The  operator  should  take  advantage  of  the  ansesthetic 
properties  of  cocaine  to  render  the  pharynx  and  larynx  tolerant  of 
manipulation.  Nitrate  of  silver  may  also  be  used,  but  is  inferior  to 
chromic  acid. 

Avulsion,  or  tearing  away  the  neoplasm,  is  a  useful  and  frequently- 
employed  method.  For  this  purpose  various  fomis  of  forceps  have  been 
used.  Pedunculated  tumors  may  be  snared  and  cut  away  with  the 
wire  loop  of  Jarvis.  Fibromata  often  adhere  so  tenaciously  that  they 
can  not  be  torn  away  without  damage  to  the  larynx.  Care  should  be 
taken  to  regulate  the  force  so  that  injury  to  the  vocal  bands  or  the  smaller 
cartilages  may  be  avoided. 

The  operation  of  thyrotomy — heretofore  described — gives  the  best 
command  of  the  cavity  of  this  organ,  and  allows  the  more  thorough  and 
safe  removal  of  the  neoplasm. 

Neoplasms  similar  in  character  to  those  found  in  the  larynx  may 
occur  in  the  trachea  and  bronchi.  The  location  of  the  new  growth  may 
be  determined  from  the  physical  signs. 

The  treatment  is  strictly  surgical,  and  involves  physical  exploration 
of  the  respiratory  tract,  with  avulsion  or  excision  of  the  growth,  or  the 
introduction  of  the  trachea-tube  to  jjrevent  asphyxia. 


PHARYNX   AND   (ESOPILVGUS. 


459 


Pharynx  and  (Esophagus. 

Pharynx. — Neoplasms  of  the  walls  of  this  cavity  are  comparatively 
rare.  They  occur  usually  in  the  vault,  and  are  attached  to  the  mucous 
membrane  beneath  the  basilar  process.  The  treatment  consists  in  re- 
moval by  the  snare  or  by  the  galvano-cautery.  AVhen  a  tumor  of  any 
considerable  size  is  to  be  removed  by  the  knife,  it  is  a  wise  precaution  to 
jierform  tracheotomy,  insert  a  tube,  and  tampon  the  pharynx  as  a  pre- 
liminary measure. 

Foreign  bodies  are  not  infrequently  lodged  in  this  organ.  They  may 
be  discovered  by  inspection  witli  the  pharyngoscope,  or  felt  with  the 
index-finger. 

Retropharyngeal  abscess  follows  in  a  certain  proportion  of  cases  in 
which  the  foreign  body  is  not  removed  soon  after  its  in- 
troduction. 

The  treatment  is  removal  by  the  aid  of  the  mirror  and 
the  curved  forceps. 

(Esophagus. 


Rupture  of  the  oesophagus,  though  several  instances 
are  recorded,  is  exceedingly  rare.  The  accident  occurs 
in  forced  efforts  at  deglutition  after  great  distention  of 
the  stomach  by  over  eating  and  drinking.  The  symp- 
toms are  intense  pain  in  the  region  of  the  rupture — 
which  is  usually  in  the  long  axis  of  the  tube  and  near  the 
diaphragm — followed  by  rapid  and  fatal  collapse.  Vom- 
iting does  not  occiir,  although  the  contents  of  the  stom- 
ach may  be  emptied,  in  part,  into  the  mediastinum. 
Surgical  interference  is  not  justifiable.  ' 

Foreign  Bodies. — The  lodgment  of  bodies  in  the 
oesophagus,  resulting  in  partial  or  complete  occlusion,  is 
of  frequent  occurrence.  The  symptoms  depend  in  great 
part  upon  the  character  of  the  foreign  substance.  A 
shai-p  and  narrow  body — as  a  bone,  pin,  needle,  or  splin- 
ter of  wood — will  produce  pain  at  the  seat  of  lodgment, 
but  will  allow  the  passage  of  liquid  and  semi-solid  ingesta. 
Soft,  compressible  particles  of  large  size  may  completely 
occlude  the  tube  and  cause  pressure  upon  the  trachea 
sufficient  to  induce  marked  aspliyxia.  The  diagnosis 
must,  in  part,  be  based  upon  these  symptoms  and  the 
history  of  the  accident.  Pressure  over  the  seat  of  lodg- 
ment of  a  sharp  substance  will  exaggerate  the  sense  of 
pain,  while  the  inability  to  swallow  liquids  will  indicate 
the  complete  occlusion  of  the  tube.  The  introduction  of 
the  elastic  oesophageal  sound  (Fig.  oS."))  will  demonsti-ate 
the  presence  of  any  occluding  body. 


i'lo.  525. 
(Esopliaig'eal  sound 


460  A  TEXT-BOOK   ON   SURGERY. 

In  order  to  introduce  this  instrument,  lubiicate  it  with  the  white  of 
an  egg,  and  cause  the  patient  to  throw  the  head  back  so  as  to  bring  the 
axis  of  the  mouth  and  pharynx  in  line  with  that  of  tlic  o'sopliagus.  In- 
sert the  bougie  so  tliat  the  i)<)int  will  glide  over  the  root  of  the  tongue 
and  strike  the  posterior  wall  of  the  pharynx  behind  the  larynx.  The 
tongue  should  not  be  drawn  out  of  the  mouth.  8])asm  of  the  ghjttis 
will  prevent  the  instrument  passing  into  the  larynx,  while,  if  l\ept 
in  the  median  line  and  i)uslied  carefully  down,  it  will  i)ass  into  the 
oesophagus. 

The  location  of  the  foreign  body  will  be  indicated  by  stopi)age  of  the 
sound.  The  prognosis  is  favorable  when  the  occlusion  is  not  complete. 
If  the  distention  is  great  enough  to  interfere  with  resjuration,  the  grav- 
ity of  the  accident  is  increased.  Iutiammati(m,  abscess,  and  ])erforation 
of  the  tt'sophagus  may  occur  if  the  obstruction  is  not  removed  within 
the  first  few  days. 

Treatvient. — When  a  foreign  body  is  lodged  in  the  oesophagus,  and 
does  not  completely  occlude  its  caliber,  it  nuiy  usually  be  dislodged  by 
producing  emesis.  If  thefe  is  complete  obstruction,  the  act  of  vomiting 
should  not  be  excited,  nor  is  the  employment  of  a  sound  or  bougie  to 
pusli  the  object  into  the  stomach  permissible. 

When  the  substance  lodged  does  not  occlude  the  oesophagus,  and 
emesis  has  failed  to  dislodge  it,  the  umbrella-probang  (Fig.  526)  should 


TlCMAW-Oa  MY 
Fig.  526. — Bristle  probang:,  for  removing  forei<rn  bodies. 


be  introduced.      This  instrument   is   lubricated,    closed, 
and  passed  into  the  oesophagus  until  the  bristles  are  well 
beyond  the  point  of  lodgment,  when  they,  by  pressure  upon  the  whale- 
bone handle,  are  projected,  completely  tilling  the  tube,  and  the  probang 
withdrawn.     If  the  introduction  of  this  instrument  is  dilhcult  or  pain- 
ful, an  anaesthetic  should  be  administered. 

In  case  of  complete  obstruction,  where  the  danger  of  inanition  is 
threatened,  or  where  pressure  upon  the  trachea  must  be  relieved,  oesoph- 
agofovty  should  be  performed. 

The  incision  should  be  made  about  five  inches  in  extent,  along  the 
anterior  border  of  the  left  sterno-mastoid  muscle.  If  the  occlusion  is 
high  u]),  the  center  of  this  cut  should  be  opposite  the  point  of  obstruc- 
tion. If  it  is  below  the  sternal  level,  the  tube  should  be  opened  as  low 
down  as  possible.  If  necessary,  the  sternal  origin  of  the  mastoideus  may 
be  divided.  The  carotid  artery  and  jugular  vein  are  left  to  the  outer 
side.  The  thyroid  body  should  be  drawn  outward  or  lifted  upward. 
The  omo-hyoid,thyrohy(iid,  and  stemo-hyoid  muscles  should  be  held  to 
the  inner  side.  A  sound  sliould  now  be  introduced  into  the  oesophagus, 
in  order  to  serve  as  a  guide  to  the  operator.  The  opening  should  be 
made  on  the  lateral  and  pf)sterior  asjject  in  order  to  avoid  the  recurrent 
laryngeal  nei-ve.     With  the  finger  introduced  into  the  wound,  the  foreign 


(ESOPHAGUS. 


461 


'9 


body  may  be  felt  and  removed  by  the  alligator-forceps.  It  is  usual  to 
leave  the  wound  open.  For  the  first  three  or  four  days  after  the  opera- 
tion the  patient  must  be  fed  by  a  tube  introduced  through  the  mouth 
and  beyond  the  wound. 

Stricture. — Stricture  of  the  CESophagus  may  be  spasmodic  or  organic. 
Tlie  irritation  caused  by  an  organic  stricture  may  not  only  exaggerate 
the  degree  of  constriction  by  exciting  spasm  of  the  muscular  fibers  of 
this  tube  in  the  immediate  vicinity  of  the  stricture,  but  also  at  points 
remote  from  the  seat  of  the  organic  lesion. 

Organic  stricture  is  comparatively  rare.  It  may  result 
from  inflammation  of  the  oesophagus  caused  by  the  ingestion 
of  scalding  water,  strong  acids,  or  alkalies,  the  lodgment  of 
foreign  bodies,  by  wounds  of  the  neck,  the  presence  of  a  neo- 
plasm, an  aneurism,  or  by  the  local  expression  of  some  gen- 
eral dyscrasia,  as  in  syphilis. 

The  diagnosis  is  determined  by  interference  with  degluti- 
tion and  by  physical  exploration  with  the  bulbous  bougies. 

The  prognosis  is  unfavorable,  although  a  fatal  termina- 
tion may  not  be  reached  for  a  considerable  period. 

The  treatment  consists  in  dilating  the  stricture  by  means 
of  elastic  bougies,  introduced  at  intervals  of  two  or  three 
days.  These  instruments  should  be  softened  by  being  placed 
in  warm  water  for  a  few  minutes  before  they  are  used.  The 
mechanism  of  introduction  is  the  same  as  for  the  bulbous 
bougies  just  described. 

Internal  oesophagotomy  is  a  justifiable  procedure  in  cases 
of  organic  stricture  which  will  not  yield  to  careful  and  jier- 
sistent  efforts  at  dilatation.  In  its  performance  the  oesopha- 
gotome  of  Prof.  Sands  (Fig.  527)  should  be  preferred.  As 
described  by  this  surgeon,*  the  shank  of  the  instrument, 
which  is  fifteen  inches  and  a  half  in  length  and  four  milli- 
metres in  diameter,  is  a  flexible  tube,  made  of  narrow,  spiral 
steel  plate,  secured  within  by  two  pieces  of  fine  wire,  in  order 
to  prevent  stretching  or  separation  of  the  spiral  coil.  The  in- 
strument is  provided  with  a  variable  number  of  steel  bulbs, 
each  bulb  being  furnished  with  a  corresponding  knife-blade. 
The  bulb  is  firmly  fastened  by  a  screw  to  the  distal  end  of 
the  shank,  and  the  knife  is  attached  to  an  inner  flexible  steel 
rod,  manipulated  by  a  thumb-screw  at  the  proximal  end  of 
the  instrument.  By  turning  this  screw,  the  knife  is  drawn 
out  from  its  concealed  position  within  the  bulb,  the  back  of 
the  blade  sliding  over  a  firm  inclined  plane.  An  index  on  a 
dial-plate  indicates  the  amount  of  projection  of  the  blade,  the 
maximum  being  two  millimetres  and  a  half.  A  small  sliding 
ring  on  the  spiral  tube  is  used  to  indicate  the  distance  of  the  strict- 
ure from  the  incisor  teeth.     The  bulb  being  conical,  the  operator  can 


Fio.  527. 

Prof.  Sandn's 

oesophago- 

toine. 


*  "  Xew  York  Medical  .Journal,''  February,  ISS-t. 


462  A  TEXT-BOOK   ON   SURGERY. 

readily  perceive  when  it  comes  in  contact  with  the  stricture,  before  he 
projects  the  blade.  In  operating,  a  bulb  juust  be  employed  which  ex- 
actly fits  the  stricture;  the  depth  ni'  the  incision  will  then  just  equal 
the  distance  to  which  the  blade  is  jjrojected  by  the  action  of  the  screw 
in  the  handle.  The  bulb  is  introduced  beyond  the  stricture,  and  the 
instrument  withdrawn  until  the  shoulder  of  the  bulb  indicates  that  it 
is  in  contact  with  the  inferior  or  gastric  border  of  the  stricture.  It  is 
then  turned  so  that  the  knife  is  posterior,  the  screw  in  the  handle  which 
projects  the  lilade  is  turned  to  the  required  extent,  and  the  constricting 
band  divided  by  pulling  the  instrument  outward  until  resistance  ceases. 
The  blade  is  then  concealed  and  the  a'sophagotome  withdrawn.  The 
dilating  bougies  may  be  introduced  at  once,  or  this  may  be  jxjstponed 
for  twenty-four  hours.  The  danger  to  be  guarded  against  is  an  incision 
through  the  wall  of  the  oesophagus.  With  the  instrument  of  Prof. 
Sands  this  is  scarcely  possible,  especially  when  the  smaller  bulbs  are 
used,  since  the  greatest  projection  of  the  blade  is  only  a  little  more  than 
one  twelfth  of  an  inch. 

When  the  occlusion  is  so  complete  that  the  oesophagotome  can  not 
be  employed,  or  if  for  any  reason  this  method  of  procedure  is  contra- 
indicated  and  inanition  is  threatened,  the  operation  of  gastrotomy  is  im- 
perative. It  is  not  only  to  be  commended  in  permanent  occlusion  of  the 
oesophagus  from  stricture,  a  diverticulum,  or  neoplasm,  Init  in  those 
cases  in  which  extensive  inflammation  has  resulted  from  the  ingestion 
of  corrosive  substances.  In  this  last  condition  the  operation  is  intended 
to  keep  the  organ  at  rest  during  the  jn-ocess  of  repair,  in  which  nothing 
but  water  is  passed  through  the  oesophagus. 

Operation. — Beginning  near  the  xiphoid  appendix,  an  incision  four 
inches  in  length  is  made,  jiarallel  with  and  from  one  half  to  one  inch 
distant  from  the  costal  cartilages  of  the  left  side.  Strict  antisei)sis 
should  be  employed,  and  all  bleeding  thoroughly  stopped  before  the 
parietal  layer  of  the  peritonfeum  is  divided.  AVhen  this  is  done  the 
index-finger  should  be  introduced  and  the  stomach  sought  for.  If  the 
obstruction  to  the  oesophagus  is  of  long  standing,  the  organ  will  be  found 
contracted  and  much  smaller  than  normal.  When  the  anterior  wall  is 
made  out,  it  should  be  seized  with  a  forceps  or  tenaculum,  drawn  up  to 
the  wound  in  the  abdomen,  and  held  in  this  position  by  an  assistant. 
The  wound  in  the  abdominal  wall  should  now  be  closed  from  each  end, 
leaving  an  opening  from  one  and  a  half  to  two  inches  in  length.  The 
sutures  should  be  of  silk  or  silver  wire,  and  should  pass  through  the 
integument  and  the  parietal  reflection  of  the  peritonjeum  wherever  the 
serous  membrane  has  been  divided. 

The  anterior  wall  of  the  stomach  is  now  secured  to  the  margins  of 
the  wound  in  the  following  manner :  Fine  sutures  of  iron-dyed  silk  are 
carried  at  intervals  of  from  one  eighth  to  one  quarter  of  an  inch  throiagh 
the  integument  at  a  like  distance  from  the  edge  of  the  incision,  passing 
through  the  parietal  peritonjeum  and  into  the  wall  of  the  stomach,  be- 
tween the  muscular  and  peritoneal  layers  of  this  organ.  The  needle 
should  run  beneath  the  peritoneal  layer  of  the  stomach  for  about  one 


(ESOPHAGUS.  463 

eighth  of  an  inch.  These  sutures  are  carried  entirely  around  the  ellip- 
tical opening,  in  this  way  uniting  the  peritoneal  layer  of  the  stomach 
with  that  of  the  abdominal  wall  and  the  integument.  It  is  best  not  to 
open  into  the  stomach  until  after  the  exjjiration  of  from  thirty-six  to 
forty-eight  hours,  by  which  time  union  will  have  occurred  between  the 
contiguous  layers  of  peritonfeum,  and  the  danger  of  infiltration  into  the 
cavity  of  the  abdomen  avoided.  If  the  necessity  for  nourishment  is 
extreme,  and  rectal  alimentation  can  not  be  relied  upon  to  sustain  tlie 
patient,  a  quantity  of  milk  or  liquid  food  may  be  injected  by  means  of  a 
medium-sized  aspirator-needle  passed  through  the  anterior  waU  of  the 
stomach.  When  the  incision  is  made  it  should  be  from  three  quarters 
to  one  inch  in  length. 

Liquid  or  semi-soUd  articles  of  food  may  be  introduced  directly  into 
the  stomach,  or,  as  practiced  in  the  remarkable  case  of  Dr.  L.  L.  Staton, 
of  North  Carolina,  the  food  may  be  masticated  and  thus  submitted  to 
the  action  of  the  saliva,  and  may  then  be  forced  from  the  mouth  into 
the  stomach  through  a  tube. 

New  Formations. — EpitJielioma  is  the  most  common  neoplasm  met 
with  in  the  oesophagus.  Colloid  and  medullary  cancer  and  sarcoma  are 
rare  in  this  organ.  Cancer  occurs  usually  between  the  thirty-fifth  and 
sixty-fifth  year  of  life.  The  favorite  location  is  near  the  diaphragm. 
Tlie  symptoms  of  malignant  growth  are  chiefly  those  due  to  obstruction 
and  the  development  of  the  cancerous  cachexia. 

Non-malignant  neoplasms  are  slower  in  development,  and,  beyond  the 
dysphagia  they  may  produce,  do  not  affect  the  general  condition  of  the 
patient. 

Treatment. — Malignant  new  growths  of  the  oesophagus  always  justify 
a  gi-ave  prognosis,  esjiecially  so  when  situated  in  the  lower  portions  of 
this  organ.  Beyond  palliative  treatment  by  dilatation  with  bougies,  or 
gastrotomy  after  deglutition  is  seriously  impaired  or  impossible,  nothing 
can  be  done.  Non-malignant  neoplasms  are  also  not  amenable  to  surgi- 
cal interference  when  situated  below  the  level  of  the  upper  border  of  the 
sternum.  When  the  upper  portion  of  the  (Esophagus  is  involved,  opera- 
tion is  indicated,  not  only  to  relieve  dysphagia,  but  in  the  effort  to  re- 
move the  disease. 

(Esophagectomy,  or  exsection  of  a  portion  of  this  organ,  may  occa- 
sionally be  justified  in  the  removal  of  a  malignant  growth  of  limited 
extent  and  situated  in  the  upper  portion  of  the  tube.  The  probability 
that,  before  the  character  of  the  neoplasm  is  discovered,  infiltration  of 
the  neighboring  tissues  will  have  occurred,  almost  precludes  a  favorable 
result,  and  is  therefore  a  strong  argument  against  the  propriety  of  the 
operation. 

Diverticula,  or  iwuches  communicating  with  the  cavity  of  the  a?soph- 
agus,  are  occasionally  met  with.  They  may  be  congenital,  but  are  more 
frequently  acquired.  They  communicate  with  the  oesophagus  usually  on 
its  posterior  wall.  Cervical  (Esophageal  diverticula  open  into  the  main 
tube  at  the  junction  of  the  oesophagus  with  the  pharynx,  whence  the 
pouch  may  extend  between  the  vertebral  column  and  the  oesophagus 


464  A  TEXT-BOOK  ON  SURGERY. 

as  fai'  down  as  the  l)ifurcation  of  tlie  tracliea.  Thoracic  cesophagea'l 
diverticula  occur  most  frequently  opposite  the  origin  of  the  bronchi. 

The  cn//s-t'.s  of  these  abnoi-nial  ])oiiches  are  various.  As  stated,  they 
may  be  the  result  of  a  failure  in  normal  development.  A  stricture  of 
the  oesophagus  may  lead  to  a  dilatation  and  pouching  of  this  organ  in 
tliat  yiortiou  immediately  above  the  seat  of  constiiction.  Degeneralion 
of  the  muscular  libers  of  the  tube  in  a  limited  area  may  lead  to  a  hernia 
of  the  mucous  membrane,  in  which,  by  the  impaction  of  ingested  matter, 
a  diverticulum  is  formed.  Ulceration  of  the  lining  meuibrane  at  any 
point,  and  from  any  cause,  may  lead  to  the  development  of  a  sac  or 
pouch  by  the  infiltration  of  ingesta  behind  the  mucous  membrane.* 

The  diagnosis  of  these  diverticula  is  made  with  great  difficulty,  and 
little  hope  of  relief  is  offered,  even  when  the  cliaracter  of  the  lesion  is 
recognized. 

The  presence  of  the  tumor  is  indicated  by  dysphagia,  and  this  symp- 
tom may  vary  in  severity  with  the  act  of  deglutition  which  carries  food 
into  the  pouch.  Dyspnoea  may  be  present  as  the  result  of  pressure 
upon  the  trachea  and  bronchi,  and  phonation  may  be  interfered  with  if 
the  pneumogastric  or  recurrent  laryngeal  nerves  are  involved. 

The  treatment  is  chiefly  palliative,  and  consists  in  .the  use  of  liquid 
diet. 

Fistula  of  the  oesophagus  may  occur  as  a  result  of  a  penetrating 
wound,  or  from  an  abscess  or  ulceration  which  destroys  a  portion  of  the 
oesophageal  wall.  A  few  instances  of  supposed  congenital  fistula  have 
been  reported. 

The  diaf//wsis  will  depend  upon  the  passage  of  ingested  matter 
through  the  outer  opening,  or  the  successful  introduction  of  a  probe 
from  without. 

The  treatment  is  surgical,  and  on  the  same  principle  as  applied  to  all 
fistulous  tracks ;  they  should  be  laid  open  by  incision,  packed  to  arrest 
bleeding,  and  afterward  allowed  to  close  by  granulation.  Or,  as  in  the 
recent  procedure  for  the  relief  of  fistula  in  ano,  the  lining  membrane  of 
the  fistula  may  be  dissected  away  and  the  wound  closed  throughout  with 
catgut  sutures. 

*  Rokitansky  has  advanced  the  theory  that  thoracic  diverticula  result  from  atrophy  of  the 
bronchial  lymphatic  glands,  which  are  situated  on  the  anterior  and  lateral  aspects  of  the 
flesophagus. 


CHAPTER  XVI. 

THOEAX. 

Mammary  Gland — Congenital  Defects. — One  or  both  of  these  organs 
may  be  absent ;  one  may  develop  fully  while  the  otlier  remains  in  its 
primitive  condition;  there  maybe  three,  four,  or  five,  the  supernumerary 
glands  being  placed  upon  the  back,  abdomen,  axilla,  or  thigh.  The 
nipple  may  be  absent  or  retracted,  and  may  be  bitid  or  multiiDle,  as  many 
as  a  half-dozen  occurring  within  the  limit  of  the  areola. 

Inflammation,  of  the  nii:)ple  is  usually  traumatic,  occurring  at  the 
early  period  of  lactation,  and  being  caused  by  pressure  from  the  gums 
of  the  infant.  It  may  also  be  involved  in  the  extension  of  a  mammitis 
along  the  galactiferous  ducts. 

The  first  indication  in  treatment  is  to  give  the  organ  rest.  A  rubber 
shield  may  be  used  to  prevent  injury  while  nursing,  or  the  child  kept 
away  from  the  breast,  the  distention  of  the  gland  being  relieved  by  arti- 
ficial means.  Poultices  of  flax-seed  or  other  emollients  should  be  applied 
during  the  acute  inflammatory  process. 

Abscess  of  the  nipple  and  the  contiguous  skin  and  subcutaneous  tis- 
sue is  an  occasional  sequence  of  inflammation  of  the  nipple. 

The  treatment  is  evacuation  of  the  jjus  by  one  or  more  incisions  made 
in  the  axis  of  the  efferent  ducts. 

Eczema.,  ov  fissure  of  the  nipple,  is  of  frequent  occurrence  during  lac- 
tation. It  is  always  annoying,  and  at  times  causes  severe  pain.  Every 
source  of  irritation  should  be  removed.  If  the  integument  is  inflamed, 
poultices  should  be  applied,  and,  after  the  acute  inflammation  subsides, 
the  closure  of  the  fissures  may  be  hastened  by  the  local  use  of  glycerite 
of  tannin  or  other  astringent.  Chronic  inflammatory  processes  of  the 
nijiple  which  are  intractable,  resisting  all  constitutional  and  local  reme- 
dies, demand  free  incision  and  ablation  of  the  diseased  area. 

Epithelioma  is  the  most  frequent  form  of  malignant  neoplasm  of  the 
nipple.     The  treatment  is  free  excision. 

Papilloma,  fibroma,  angioma,  cysts,  etc.,  may  occur  in  this  organ, 
and  should  be  removed  by  the  knife  as  soon  as  discovered. 

3Iasfitis. — Inflammation  of  the  breast  may  be  acute  or  chronic,  trau- 
matic or  idiopathic.  A  single  lobule  or  subdivision  of  the  gland  or  the 
entire  organ  may  be  involved.  In  the  more  severe  forms  of  inflammation 
the  process  may  extend  along  the  ducts  to  the  nipple  and  backward  into 
the  submammary  connective  tissues. 

3U 


466  A  TEXT-BOOK  OX  SURGERY. 

Traumatic  mastitis  is  usually  circumscribed,  the  integument  and  sub- 
cutaneous areolar  tissue  being  also  involved.  The  deeper  tissues  escape 
unless  great  and  uinisnal  violence  has  ])een  inflicted. 

Idiopathic  mastitis  is  almost  always  connected  with  lactation,  occur- 
ring usually  during  the  first  few  weeks  after  parturition.  In  rare  cases 
it  occurs  at  intervals  in  non-jiregnant  females,  the  symptoTns  of  this  dis- 
order being  associated  periodically  with  the  menstrual  function.  Mas- 
titis is  also  a  symptom  of  parotitis  or  '■'■mumps." 

The  milder  forms  which  occur  during  lactation  are  little  nioi-e  than 
exaggerations  of  the  normal  functions  of  this  organ,  while  the  more 
typical  pathological  process,  commencing  in  the  hyper;emia  of  the  secre- 
tory apparatus,  is  exaggerated  by  obstruction  to  the  escape  of  the  milk 
through  the  galactiferous  ducts.  This  obstruction  may  occur  at  any  por- 
tion of  the  efferent  ducts,  although  the  occlusion  is  usually  situated  in 
or  near  the  nipple.  Distention  of  the  duct  and  its  subdivisions  leading 
back  to  the  acini  follows,  and  intiammation  ensues  in  the  enth'e  limit  of 
obstruction. 

Si/rajytoms. — The  first  indications  of  inflammation  of  the  mammary 
gland  are  pain  and  localized  induration.  The  pain  is  constant,  and 
usually  severe  in  character,  and  may  extend  along  the  ribs  to  the  axilla. 
The  induration  is  usually  well  defined,  and  may  consist  of  one  or  more 
nodules.  Injection  of  the  skin  is  marked  over  the  area  of  induration." 
The  temperature  is  elevated  one  or  two  degrees,  the  pulse  increased  in 
frequency,  and  a  well-pronounced  chill  or  a  series  of  rigors  is  apt  to  be 
a  feature  of  the  earlier  stages  of  this  disease. 

Treatment. — As  soon  as  inflammation  is  threatened  the  breast  should 
be  supported  by  a  bandage,  or  long,  soft  towel,  or  handkerchief  thrown 
around  the  neck  and  slujulder  and  beneath  the  gland,  holding  it  in  the 
I)osition  of  least  discomfort.  In  the  stage  of  hypersemia  the  application 
of  a  light  ice-bag,  with  limited  compression  of  the  organ,  is  advisable. 
The  nipple  should  be  kept  moistened  with  a  tuft  of  cotton  saturated 
with  vaseline  or  oil,  which  is  placed  in  position  before  the  ice-bag  is 
applied.  Careful  attention  should  be  given  to  the  frequent  evacuation 
of  the  milk.  When  the  nipple  is  inflamed,  artificial  means  should  be 
employed  to  empty  the  breast.  If  the  inflammatory  process  does  not 
yield  to  this  treatment  after  the  first  few  days,  it  should  be  abandoned 
and  warm  poultices  applied.  It  is  important  to  recognize  the  earliest 
collection  of  pus,  and  to  relieve  it  by  aspiration  or  incision.  Indeed, 
when  the  induration  is  localized  and  well  marked,  it  is  good  practice 
to  explore  under  cocaine  with  the  large  hypodermic  needle  to  determine 
the  presence  of  suppuration.  If  no  pus  be  found,  the  puncture  does 
no  harm,  and  of  itself  often  affords  relief  from  tension. 

When  abscess  exists  the  pus  should  be  freely  evacuated  by  aspira- 
tion or  incision.  If  the  collection  is  deep-seated,  requiring  an  incision 
through  a  considerable  area  of  gland-tissue,  aspiration  may  be  tried  and 
repeated  for  two  or  three  times.  By  the  relief  of  tension,  resolution 
may  be  induced.  When  fluctuation  is  evident,  and  only  the  integument 
intervening,  incision  is  preferable.     This   may  be  done  without  pain, 


THORAX.  467 

and  ofifers  the  speediest  and  surest  means  of  cure.  The  incision  should 
be  parallel  with  the  direction  of  the  galactiferous  ducts.  When  the 
cavity  is  opened,  the  nozzle  of  the  irrigator  should  be  introduced  and 
the  abscess  thoroughly  washed  out  with  l-to-3000  su])limate  solution. 
Drainage  should  be  secured,  and  a  loose  dressing  applied.  The  point 
of  incision  should  be  made  in  the  lower  portion  of  the  .sac,  so  that  drain- 
age may  be  free.  At  times  it  may  be  necessary  to  make  a  counter-open- 
ing. Less  fi-equently  abscess  may  form  in  front  of  the  glandular  tissue 
beneath  the  integument  or  between  the  capsule  of  the  gland  and  the 
thorax.  Ostitis  or  periostitis  of  the  ribs  maj^  be  the  cause  of  deep- 
seated  stibmammary  abscess. 

Ili/pcrfrophy  of  the  mammary  gland  is  a  normal  process,  usually 
occui'ring  at  puberty  and  during  pregnancy  and  lactation.  In  rare 
instances  there  is  an  extensive  hyi^erplasia  of  the  connective-tissue  ele- 
ments of  this  organ,  resulting  in  gi-eat  enlargement.  The  diagnosis  may 
be  based  upon  the  hard  character  of  the  mass,  there  being  none  of  the 
softness  and  elasticity  which  belong  to  the  normal  breast.  The  hyper- 
plasia is  general,  involving  the  entire  framework  of  the  organ,  which 
will  render  it  easy  of  differentiation  from  any  form  of  neoplasm,  for  these 
grow  from  recognized  centers  of  induration.  The  diagnosis  meets  with 
confirmation  if  the  enlargement  takes  place  after  puberty,  and  in  a  non- 
pregnant woman. 

In  the  treatment  of  this  condition  the  hyperplasia  may  be  arrested 
in  the  earlier  stages  by  well-adjusted  and  prolonged  compression.  This 
may  be  effected  by  a  thick  layer  of  alisorbent  cotton  laid  over  the 
breast  and  held  firmly  down  iipon  it  by  a  roller,  applied  as  directed 
on  pages  16  and  17.  In  advanced  cases,  a  free  excision  of  the  organ  is 
demanded. 

Tumors  of  the  Breast. — New  formations  in  the  mammary  gland  are 
among  the  more  frequent  surgical  diseases.  The  microscopical  charac- 
ters of  tumors  are  elsewhere  described.  Unfortunately,  they  are  more 
frequently  vuClifjnant  than  benign.  Although  tumors  of  the  breast  occur 
chiefly  in  females,  they  are  not  uncommon  in  males.  Among  the  non- 
malignant  tumors  are  adenoma.,  myxoma,  fibroma,  and  enchondroma. 
Various  forms  of  cysts  are  also  met  with,  while  syphilitic  gumma  and 
tubercular  deposits  may  occur  in  this  organ.  Carcinoma  (scirrhiis,  en- 
cephaloid,  colloid,  and  epithelioma)  and  sarcoma  are  the  malignant  neo- 
plasms which  are  found  in  the  breast. 

Adenoma  of  the  mammary  gland  is  rare.  The  pathological  change, 
a  hyperplasia  of  the  glandular  tissue  proper,  is  usually  circumscribed. 
The  tumor  is  generally  of  small  size,  freely  movable  with  the  breast,  and 
does  not  form  adhesions  with  the  capsule,  integument,  or  submammary 
fascia.  There  is  no  inflammatory  process  connected  with  its  develop- 
ment, no  enlargement  of  the  axillaiy  glands,  no  dilatation  of  the  veins 
of  this  region,  and  little  or  no  pain.  It  is  found  in  nursing  women  as  a 
rule,  but  may  occur  in  early  puberty  and  in  women  who  have  not  borne 
children.  It  is  not  the  rule  for  cystic  degeneration  to  take  place  in  this 
neoplasm,  although  such  cysts  may  be  met  with  in  rare  instances  as  a 


468  A  TEXT-BOOK   ON  SURGERY. 

result  of  degeneration  of  the  new-formed  cells  of  the  deeper  portions  of 
the  growth. 

Adenoma,  of  itself  a  benign  neoplasm,  is  thought  by  some  patholo- 
gists to  be  capable  either  of  developing  into  carcinoma,  or  of  exciting 
the  carcinomatous  change  in  the  organ.  Not  only  in  the  simple  circum- 
scribed form  of  this  neoplasm,  but  in  that  variety  sometimes  called 
tubular  adenoma,  in  which  the  hyperplasia  of  the  glandular  cells  is 
not  confined  to  the  acini  and  terminal  ducts,  but  extends  into  and  in- 
volves the  galactiferous  ducts  as  far  as  the  nipple,  and  which  is  more 
generally  diffused  tlian  in  the  simpler  form  above  described,  it  is  ad- 
mitted that  the  transformation  into  carcinoma  is  possible  and  at  times 
rapid. 

Treatment. — The  tumor  should  be  excised.  When  a  considerable 
portion  of  the  gland  is  involved,  the  entire  organ  should  l)e  extirjjated 
on  account  of  the  tendency  to  recuiTence  in  this  neoplasm.  If  the  tumor 
is  small  it  may  be  removed  by  sacrificing  only  that  part  of  the  gland- 
tissue  immediately  around  it.  Ujwn  the  recurrence  of  the  growth,  the 
entire  breast  should  be  excised. 

Myxoma  is  very  rarely  met  with  in  the  mammary  gland.  It  may 
occur  as  a  single  nodule  and  develop  slowly  froin  a  single  center,  or  it 
may  develop  from  several  centers  and  rapidly  invade  the  entire  organ. 
It  is  not  adherent  to  the  skin  until  inflammatory  adhesions  occur  pre- 
liminary to  ulceration  of  the  mass.  Infiltration  of  the  axillary  glands 
occurs  only  as  a  result  of  inflammation.     The  nipple  is  not  retracted. 

The  prognosis  is  favorable  if  the  tumor  is  discovered  early  in  its 
development,  and  if  in  the  excision  a  sufficient  portion  of  healthy  tissue 
is  removed  with  the  neoplasm.  The  treatment  is  free  excision.  The 
entire  gland  should  be  sacrificed,  and,  if  the  organ  is  wholly  involved, 
the  line  of  incision  should  be  well  out  from  the  limits  of  the  tumor  in 
the  healthy  tissues. 

Fibroma  of  the  mammary  gland  may  occur  at  any  period  of  life.  It 
is  rarer  in  the  aged  than  in  the  young,  occurring  mosth"  in  persons  under 
forty,  and  occasionally  under  puberty.  This  form  of  connective-tissue 
hyperplasia  may  affect  the  entire  organ  (as  in  general  hypertrophy, 
already  described)  or  a  circumscribed  area.  A  nodular  or  ciirumscribed 
fibroma  is  a  hard,  dense  tumor,  freely  movable  with  the  gland,  and  may 
or  may  not  be  painful.  Shrinkage  of  the  breast  occurs  at  times  as  a 
result  of  the  cicatricial  contraction  of  the  new-formed  tissue,  and,  when 
near  the  nipple,  its  retraction  may  resemble  that  of  scirrhus.  As  a  rule, 
this  vai-iety  of  tumor  is  of  slow  development.  Not  infrequently  it  un- 
dergoes cystic  degeneration.  The  axillary  glands  are  not  involved,  nor 
do  adhesions  occur  until  after  atrophy  of  the  gland  with  retraction  of 
the  new-formed  connective  tissue.  It  should  be  removed  by  the  same 
wide  and  free  excision  as  recommended  for  myxoma. 

Enehondroma  of  the  breast  is  very  rare.  It  is  apt  to  be  circum- 
scribed. Calcification  has  been  observed  in  some  of  the  few  recorded 
cases  of  this  neoplasm.  Occasionally  it  is  found  with  carcinoma.  En- 
chondroma  of  the  breast  should  be  freely  excised. 


THORAX,  469 

Cysts. — Among  the  various  forms  of  cystic  tumors  found  in  this  gland 
are  galactocele,  sanguineous,  dennoid,  and  hydatid  cysts,  and  the  forms 
whicli  occur  in  the  degeneration  of  adenoma,  fibroma,  myxoma,  and  car- 
cinoma. 

Galactocele  is  a  cyst  caused  by  obstructicm  of  the  ducts  whicli  convey 
the  milk  toward  the  nipple.  The  oljstruction  is  followed  by  distention 
of  the  tubes  and  acini.  Examined  with  the  microscope,  the  contents  of 
these  cysts  consist  of  epithelial  cells  in  various  stages  of  granular  meta- 
morjihosis,  and  milk-globules. 

The  diagnosis  may  be  determined  by  aspiration.  The  treatment  con- 
sists in  incision  and  evacuation  of  the  contents  with  drainage  until  the 
cyst  may  be  obliterated  by  the  process  of  granulation. 

Dermoid  and  hydatid  cysts  are  exceedingly  rare  in  this  situation. 
The  diagnosis  may  be  determined  by  aspii-ation,  and  the  proper  treat- 
ment is  excision.  Cysts  may  occur  in  the  breast  from  the  extravasation 
of  blood  after  contusions,  or  from  the  non-traumatic  rupture  of  blood 
or  lymph  vessels.     They  heal  readily  after  incision  and  drainage. 

Tuberculosis  of  the  breast  is  rare.  The  nodules  may  be  disseminated 
generally  through  the  gland  or  beneath  the  capsule,  or  there  may  be  one 
or  more  large  collections.  They  are  hard  to  the  touch.  The  history  of 
the  case  will  aid  in  detemiining  the  character  of  the  lesion. 

If  there  is  no  general  dissemination  of  tubercular  matter — that  is,  if 
the  disease  is  limited  to  the  mammary  gland — this  organ  should  be  fi-eely 
excised. 

Sarcoma  of  the  breast  attacks  usually  the  young  and  middle-aged. 
It  is  rarely  general  in  its  development,  but  commences  as  a  single  nod- 
ule, more  apt  to  occupy  the  iipper  portion  of  the  organ  than  the  lower, 
whence  it  invades  the  gland  and  circumjacent  structures  in  every  direc- 
tion. The  rapidity  with  which  it  grows  depends  in  part  upon  the  micro- 
scoj)ical  character  of  the  neoplasm,  and  in  i)art  upon  the  age  of  the  pa- 
tient. Sarcoma  develops  more  rapidly  in  the  young,  and  the  round-ceU 
sarcoma,  which  variety  is  most  frequently  met  with  in  the  breast,  is 
more  rapid  in  its  develoiiment  than  the  si)indle-cell  sarcoma.  In  the 
earlier  stage  this  tumor,  though  firm  and  nodular,  is  freely  movable 
with  the  gland.  Its  growth,  however,  is  often  so  raj^id  that  the  skin 
and  subcutaneous  tissues,  the  submammary  fascia,  and  the  muscles  of 
the  chest  become  involved,  the  breast  stands  out  full  and  tense,  and  be- 
comes immoval)le.  The  superficial  veins  are  greatly  enlarged.  As  a 
rule,  the  lymphatic  glands  of  the  axilla  are  not  involved  until  suppura- 
tion of  the  mass  induces  axillary  adenitis. 

DilTerentiation  between  round  and  spindle-cell  sarcoma  is  difficult 
unless  the  tumor  is  examined  with  the  microscope.  Practically,  the  dif- 
ferentiation is  not  important.  The  first  variety  is  softer  to  the  touch, 
more  rapid  in  growth,  and  is  more  vascular.  It  is  apt  to  occur  in  the 
younger  class  of  patients. 

Both  forms  of  sarcoma  tend  to  the  fonnation  of  cysts  within  their 
sti'ucture.  As  stated,  they  may  be  due  to  fatty  degeneration  of  the  em- 
bryonic elements  of  the  tumor,  or  may  result  from  caverns  of  blood 


470  A  TEXT-BOOK  OX  SURGERY. 

which  have  become  cut  off  from  the  general  circulation  through  the 
tumor. 

The  (liai^no.sis  of  sarcoma  of  the  breast  depends  upon  tlie  aire  of  the 
patient,  tlie  rajjidity  of  its  growth,  and  the  absence  of  axillary  engorge- 
ment.    The  treatment  consists  in  free  excision. 

Carcinoma  is  by  far  the  most  common  firm  of  neoplasm  met  M'ith  in 
the  breast.  The  order  of  prevalence  of  the  four  varieties  is  sci/r/iiis, 
encephaloid,  colloid,  and  epithelioma.  Cancer  of  the  mammary  gland 
occurs  in  I'are  instances  in  males.  In  women  it  is  met  with  most  fre- 
quently in  the  period  from  the  fortieth  to  the  sixtieth  years  of  life.  It 
may  occur  later  than  this,  and  is  rarely  seen  earlier  than  the  age  of 
thirty.  Women  who  have  never  been  pregnant  are  affected,  though 
probably  not  so  liable  as  those  who  have  borne  children. 

Scirrhus  of  the  breast  appears  usually  as  a  single  hard  nodule  or 
lump,  situated  in  the  substance  of  the  gland,  movable  within  rhis  organ, 
but  firmly  imbedded  in  it ;  or  two  or  more  nodules  may  appear  simul- 
taneously in  different  parts  of  the  gland,  which  eventually  approach 
each  other  so  as  to  form  a  nodulated  mass.  The  growth  of  scin-hus  is, 
as  a  rule,  not  rapid  in  the  earlier  stages  of  its  development,  but,  after 
reaching  a  certain  size,  it  spreads  with  increasing  rapidity.  The  length 
of  time  which  may  elapse  between  the  commencement  of  the  neoplasm 
and  metastasis  in  the  subpectoral  and  axillary  lymphatics  varies  in  dif- 
ferent individuals.  It  is,  however,  in  general  proportionate  to  the  rajiid- 
ity  of  the  growth  of  the  neoplasm.  Pain,  which  is  a  symptom  of  this 
disease,  is  lancinating  in  character  rather  than  dull  and  continuous.  It 
is  usually  more  severe  in  tumors  which  develop  rapidly. 

Cancer  of  thebreast  may  assume  the  form  of  a  single  large,  rounded, 
and  nodular  mass,  or  nodules  of  various  sizes  may  develop  in  the  organ 
or  be  scattered  in  knots  or  groups  beneath  the  integument,  in  the  pec- 
toral muscles,  or  along  the  line  of  lymphatics  leading  into  the  axilla. 
If  left  unmolested,  scirrhus  soon  invades  the  tissues  around  the  breast, 
the  muscles  of  the  chest  becoming  infiltrated,  the  skin  attached  to  the 
mass,  and  the  nipple  retracted.  On  account  of  pressure  the  circulation 
in  the  most  remote  portions  of  the  invaded  gland  is  interfered  with,  and 
ulceration  ensues,  giving  rise  to  a  more  or  less  extensive  granulating  sur- 
face, from  which  there  is  a  discharge  of  a  serous-like  fluid  containing 
blood-coii3iiscles,  embryonic,  pus,  and  cancer  cells.  In  the  later  stages 
lymphatic  engorgement  is  more  extensive,  and  the  effects  of  compres- 
sion upon  the  thoracic  and  axillary  nerves  more  evident.  Not  infre- 
quently the  subclavicular,  supraclavicular,  and  cei-vical  lymphatics  be- 
come engorged.  Pressure-symptoms  are  not  alone  confined  to  the  nei"ves, 
but  the  interference  with  the  return  circulation  in  the  axillary  vein  may 
produce  general  oedema  of  the  extremity. 

EncepTialoicl  cancer  of  the  breast  differs  only  in  degree  from  the 
scirrhous  variety.  It  is  softer  tinder  pressure,  grows  \vith  much  greater 
rapidity,  ulcerates  earlier  and  more  extensively,  is  more  prone  to  hfem- 
orrhages,  and  tends  to  a  more  rapidly  fatal  termination.  It  is  more  apt 
to  recur  after  removal. 


THORAX.  471 

Epithelioma  of  the  breast  is  rare.  It  commences  in  or  near  the  nip- 
ple, and  may  extend  along  the  epithelial  lining  of  the  lactiferous  ducts, 
or  spread  along  the  integument  of  the  areola.  Although  ulceration 
begins  earlier,  its  progress  is  slower  and  less  painful  than  in  either  of 
the  forms  of  cancer  just  given,  which  attack  the  deeper  structures  of 
the  gland.  If  not  extirpated,  the  entii'e  gland  may  be  infiltrated,  metas- 
tasis occurs,  and  death  follows  from  general  exhaustion. 

Prognosis  and  Treatment. — The  prognosis  of  cancer  of  the  breast  is 
always  grave,  the  gravity  varying  with  the  character  of  the  neoplasm, 
the  general  condition  of  the  patient,  and  the  length  of  time  the  tumor 
has  existed  before  excision.  Left  without  surgical  interference,  a  fatal 
termination  is  reached  usually  within  from  one  to  two  years  after  the 
appearance  of  the  disease.  Encephaloid  is  most  rapidly  fatal,  scirrhous 
next  in  order,  and  epithelioma  last.  Death  ensues  from  exhaustion 
caused  by  suppuration,  pain,  anorexia,  and  infiltration  of  the  various 
organs  by  metastasis.  In  isolated  cases  scirrhus  of  the  breast  reaches  a 
certain  point  and  remains  stationary  for  a  number  of  years  before  again 
enlarging  and  j^roducing  a  fatal  issue. 

"With  the  operation  as  performed  in  modern  practice,  the  prognosis 
is  much  more  favorable.  This  practice  implies  early  recognition  of  the 
presence  and  character  of  the  neoplasm,  immediate  and  wide  extiri)ation 
of  the  invaded  organ,  and  a  careful  dissection  of  all  metastatic  foci  in 
the  glands  of  the  axillary  plexus.  As  to  the  selection  of  cases  in  which 
operati(m  is  justifiable,  it  may  be  admitted  that  interference  is  called 
for  in  all  cases  in  which  the  lymphatic  engorgement  has  not  extended 
beyond  the  axillary  region,  and  in  which  the  invasion  of  the  pectoral 
and  thoracic  muscles  is  not  so  deep  or  extensive  that  a  clean  excision  is 
possible  without  opening  into  the  thorax.  Even  when  metastasis  of  the 
cervical  lymphatics  has  occurred,  relief  will  be  gained  in  those  instances 
in  which  ulceration  is  taking  place  ;  but,  in  these  cases,  the  palliative 
operation  should  not  include  invasion  of  the  axilla.  It  is  well  to  bear 
in  mind  that  a  simple  non-malignant  enlargement  of  the  glands  may 
occur  before  true  metastasis  has  taken  place. 

It  should  be  the  practice  in  all  cases  of  cancer  of  the  mammary  gland 
to  open  into  the  axiQa  in  order  to  be  sure  of  the  condition  of  the  glands, 
for  these  organs  may  be  the  seat  of  cancerous  infiltration  which  can  not 
be  recognized  without  incision. 

As  to  treatment,  the  following  line  of  practice  should  be  adopted : 

A  tumor  of  the  breast  occurring  in  either  sex  after  the  thirtieth  year 
of  life  should  he  excised  as  soon  as  discovered.  The  contraindications 
to  this  procediire  are:  (1)  a  condition  of  prostration  so  extreme  that  a 
surgical  operation  would  involve  great  and  unusual  risk  to  life  ;  (2)  me- 
tastasis to  such  an  extent  that  complete  removal  of  the  neoplasm  is  im- 
possible. 

The  incision  should  he  well  aicayfrom  the  limit  of  the  tumor  in  the 
healthy  tissues.  When  only  a  small  portion  of  the  organ  is  involved,  it 
is  advisable  to  extirpate  the  entire  gland.  "When  the  patient  is  under 
thirty  years  of  age,  and  when  the  tumor  is  thought  to  be  benign  in  char- 


472  A  TEXT-BOOK   ON   SURGERY. 

acter,  the  less  radical  operation  of  enucleation  of  the  neoplasm  may  be 
undertaken.  Any  new  fonnation  so  removed  should  be  carefully  exam- 
ined, and.  if  found  to  be  niali.unant,  a  wider  incision  should  be  made, 
either  at  the  Hrst  indication  of  lecurrence,  or  preferably  at  once. 

Operation. — The  patient  is  placed  iipon  the  table  with  the  chest 
slightly  elevated,  the  breast  and  axilla  of  the  affected  side  near  the 
edge.  The  arm.  intrusted  to  an  assistant,  should  be  held  at  a  right 
angle  to  tlie  body,  and  the  head  directed  to  the  opposite  side.  The 
integument  of  the  axilla  and  within  the  lield  of  operation  should  be 
shaved,  washed  with  soap  and  warm  water,  afterward  with  ether,  and 
finally  with  l-to-2000  sublimate  solution.  The  diseased  organ  should  be 
handled  as  gently  as  possible.  Sublimate  towels  should  be  laid  over  the 
exposed  surface,  leaving  only  the  part  to  be  removed  in  sight. 

The  operator  now  carefully  outlines  the  tumor,  since  it  is  essential 
that  the  incision  should  be  from  one  to  two  inches  outside  of  the  limit 
of  induration.  On  this  line  the  skin  and  subcutaneous  tissues  should 
be  divided  directly  down  to  the  muscles.  The  fascial  covering  of  the 
thoracic  muscles  should  be  dissected  up  with  the  gland.  If  the  inliltra- 
tion  has  involved  the  deeper  portions  of  the  organ,  the  pectoral  muscles 
within  the  line  of  incision  should  be  dissected  out,  leaving  nothing  but 
the  ribs  and  intercostal  muscles.  All  vessels  should  be  secured  and  tied 
with  catgut  as  fast  as  divided.  Oozing  may  be  arrested  by  pressing 
sponges  or  sul)limate  towels  into  the  wound  as  the  operation  proceeds. 

The  dissection  should  be  made  and  the  mass  lifted  from  the  sternum 
toward  the  axilla.  In  this  way  the  larger  vessels  (the  long  thoracic 
artery  and  branches)  are  not  divided  until  the  incision,  which  completely 
severs  the  tumor,  is  being  made. 

All  haemorrhage  in  the  wound  being  arrested,  and  this  filled  with 
warm  sublimate  towels  to  prevent  oozing,  the  dissection  should  be  con- 
tinued into  the  axilla.  During  this,  the  most  difficult  part  of  the  opera- 
tion, the  arm  should  be  held  immovably  at  an  angle  of  90°  to  the  axis  of 
the  spine.  From  the  end  of  the  elliptical  wound  nearest  the  axilla,  an 
incision  is  made  along  and  below  the  border  of  the  pectoralis  major 
muscle,  extending  as  far  as  the  arm.  The  integument  below  this  incision 
should  be  dissected  up  from  the  underlying  areolar  tissue  down  to  the 
posterior  fold  of  the  axilla,  blunt  retractors  placed  above  and  below, 
and  the  edges  of  the  wound  separated  as  widely  as  possible.  It  is  ad- 
visable to  remove  the  adipose  tissue  which  fills  in  tliis  space  along  with 
the  enlarged  glands.  The  cliief  danger  is  the  wounding  of  the  axillary 
vein  or  one  of  its  bi-anches  so  close  to  the  main  trunk  that  air  may  be 
admitted  or  the  ligature  have  to  be  applied  to  the  axillary  vein.  If  the 
dissection  is  made  with  blunt  scissors  curved  on  the  flat,  keeping  the  con- 
vex surface  nearest  the  vein,  and,  if  the  vessel  is  approached  from  the 
scapular  border,  this  danger  may  be  avoided.  In  this  region  the  sub- 
scapular vein  is  easily  recognized,  and  may  be  followed  toward  the  large 
trunk.  In  the  lower  portion  of  the  axilla  the  brachial  fascia  protects 
the  vein.  If  the  enlarged  glands  extend  high  up  in  the  axilla,  the  pec- 
toralis major  and  minor  should  be  cut  across   and  a  clean  dissection 


THORAX.  473 

made  as  high  as  the  clavicle  if  necessary.  When  a  hard  gland  is  found 
lying  directly  upon  the  sheath  of  the  vein,  it  may  be  removed  by  the 
thumb  and  finger-nail.  When  working  close  to  the  axillary  vein  and 
artery,  all  hjemoirliage  may  be  avoided  by  applying  forceps  on  each  side 
of  the  track  of  the  incision  before  the  scissors  are  used,  and  immedi- 
ately tying  the  tissues  grasped  with  catgut.  Occasionally  the  vein  will 
be  found  so  studded  with  metastatic  foci  that  removal  without  injury  to 
this  vessel's  wall  is  impossible.  When  this  condition  exists,  either  the 
operation  will  have  to  be  abandoned  or  the  vein  and  its  branches  tied 
above  and  lielow  the  neoplasm,  and  the  intermediate  portion  exsected. 

In  one  of  my  cases  this  operation  was  performed.  The  axillary  vein 
was  tied  near  the  clavicle,  and  the  brachial  just  below  the  tendon  of 
the  pectoralis  major,  and  double  ligatures  to  all  intervening  branches. 
The  neoplasm  had  not  recurred  two  years  after  the  operation.  The 
venous  circulation  was  well  established  through  the  cephalic  vein.  The 
patient  was  in  excellent  healtli.  When  the  operation  is  completed,  a 
drainage-hole  should  be  made  from  the  deepest  portion  of  the  wound 
(estimating  this  from  the  position  the  patient  is  to  assume  after  the 
operation)  by  carrying  the  tip  of  a  closed  di-essing-forcei^s  through  the 
tissues  until  the  skin  along  the  axillary  border  of  the  scapula  is  lifted 
by  the  instrument.  This  should  be  incised  and  the  hole  enlarged  by 
separating  the  jaws  of  the  forceps.  A  good-sized  rubber  drainage-tube 
should  be  pulled  through  from  below  as  the  forceps  are  withdi-awn.  As 
much  of  the  wonnd  is  closed  by  sutures  as  possible,  a  final  in-igation  of 
l-to-3000  sublimate  is  made,  a  loose  dressing  placed  in  the  open  portion 
of  the  wound,  and  the  usual  dressing  of  gauze  and  borated  cotton,  and 
protective  placed  over  all. 

When  a  benign  tumor  is  to  be  enucleated  from  the  breast,  the  incision 
may  usually  be  made  along  the  crescentic  fold  at  the  lower  border  of 
this  organ,  the  gland  turned  up,  the  tumor  removed,  and  the  breast  re- 
stored to  its  former  position.  The  scar  is  concealed  in  the  natural  fold 
between  the  integument  of  the  thorax  and  the  breast. 

Abscess  of  the  thoracic  walls  usually  results  from  ostitis  of  the  clavi- 
cle, sternum,  ribs,  scapulse,  or  vertebra?,  or  enchondritis  of  the  costal 
cartilages.  If  not  incised,  they  open  spontaneously  through  the  integu- 
ment and  discharge  pus  and  at  times  jiarticles  of  bone  and  other  de- 
tritus. Spontaneoiis  cure  may  occur,  although  this  is  the  exception. 
Sinuses  usually  result,  and  continue  until  the  diseased  tissues  are  ex- 
cised. The  most  common  seat  of  ostitis  is  in  the  sternum  and  the  sternal 
ends  of  the  ribs.  The  indications  in  treatment  are  to  lay  the  sinuses 
open,  carefully  following  each  to  its  terminus,  scrape  the  indurated 
lining  membiane  away  with  a  scooj),  and  remove  all  dead  bone  by 
scraping  with  the  Volkmann  spoon  or  exsection  in  mass.  Opening  into 
the  pleura  or  mediastinum  should  be  avoided.  When  the  abscess  leads 
behind  the  sternum,  as  in  a  case  which  came  under  my  care,  a  segment 
of  this  bone  should  be  removed  in  order  to  expose  and  drain  the  cavity. 
In  exsection  of  a  ]iortion  of  one  or  more  ribs,  the  incision  should  be 
made  along  the  center  of  the  bone,  the  periosteum  lifted  with  the  ele- 


474 


A  TEXT-BOOK   OX   SURGERY. 


vator  (first  from  tlie  anterior  surface  and  then  from  behind),  and  tlie 
bone  divided  with  the  exsector  or  cutting-forceps.  All  of  these  wounds 
should  be  packed  with  sublimate  gauze. 


'^"l 


>3 


Fio.  628. — Portions  of  the  left  claricle  removed  on  account  of  ostitis. 


/'^ 


^' 


0.0" 


w 


Exsection  of  the  clavicle  may  be  demanded  in  ostitis  of  this  bone. 
In  a  case  operated  iipon  by  myself  for  necrosis  resulting  from  a  disloca- 
tion at  the  sternal  end,  the  incision 
extended  the  entire  length  of  the 
bone,  and  the  excision  was  subpe- 
riosteal throughout.  A  new  and 
strong  clavicle  formed,  with  pei'fect 
motion  at  the  sternal  and  acromial 
articulations.  The  shortening  was  a 
little  less  than  one  inch.  Six  years 
after  the  operation  the  function  of 
the  injured  side  is  perfect  (Figs. 
528,  529). 

Empyema. — Pus  may  collect  in 
the  pleural  sac  as  a  circumscribed 
abscess,  or  exist  in  the  general  cav- 
ity of  the  pleura. 

The  diagnosis  may  be  determined 
from  the  elevation  of  temjierature 
iisually  present,  by  dullness  on  per- 
cussion over  the  fluid,  and  by  aspi- 
ration, using  the  smaller  needles. 
The  treatment  consists  in  evacuation 
of  the  purulent  contents  with  the  as- 
pirator, or  by  incision.  If  the  symp- 
toms of  septic  absorjition  are  not  urgent,  aspiration  may  l)e  tried  and 
repeated  at  intervals  until  recovery  ensues,  or  until  a  failure  of  this 
method  is  demonstrated.  The  contents  of  the  pleural  cavity  should  not 
be  too  rapidly  evacuated.  Fatal  syncope  has  occurred  in  several  in- 
stances during  this  operation.  Incision  should  be  done  in  all  ui-gent 
cases,  and  in  those  instances  in  which  aspiration  fails.  The  object  of 
this  operation  is  to  drain  the  cavity  of  the  abscess  at  its  most  dependent 
portion.  An  effort  should  be  made  to  determine  the  lowest  point  by  the 
introduction  of  the  needle  in  several  of  the  intercostal  spaces.  The 
opening  should  be  made  about  opposite  the  center  of  the  rib,  preferably 
a  little  posterior  to  the  middle.  The  incision  should  be  in  the  intercostal 
space,  half-way  between  the  ribs.  When  the  costal  pleura  is  divided,  it 
will  be  indicated  by  the  escape  of  pus  and  the  entrance  of  aLr.     Partial 


Fig.  529. — The  .luthor's  c:\<Vy  in  which  a  new  clav- 
icle was  formed  alter  subpuriosteal  excision. 


WOUNDS  OF  THE   CHEST.  475 

collapse  of  tlie  lung  of  the  affected  side  follows.  As  soon  as  the  incision 
is  completed  the  finger  of  the  operator  should  be  introduced  in  order  to 
determine  if  the  opening  is  near  the  bottom  of  the  cavity.  If  not,  it  is 
usually  advisable  to  make  a  second,  or  counter  opening,  on  a  lower  level. 
A  drainage-tube,  or  jireferably  two  tubes,  are  carried  side  by  side  in  at 
one  opening  and  out  at  the  other,  and  secured  by  transfixion  with  safety- 
pins.  If  a  single  opening  is  made,  the  double  tube  should  always  be 
used.  The  cavity  should  now  be  washed  out  with  l-to-3000  sublimate, 
and  a  dressing  api:)lied.  Later,  a  stronger  solution  may  be  used.  I  have 
rei^eatedly  irrigated  with  1-to-lOOO  sublimate,  with  no  poisoning. 

If  the  ribs  are  so  close  together  that  free  drainage  can  not  be  secured, 
a  portion  of  one  rib  should  be  exsected.  The  ojiening  should  be  large 
enough  to  admit  the  index-finger. 

Ostitis  or  other  diseases  of  the  scapula  do  not  require  especial  con- 
sideration.    Removal  of  any  portion  or  aU  of  this  organ  may  be  effected. 


Wounds  of  the  Chest. 

Wounds  of  the  chest  are  divided  into  penetrating  and  non-penetrat- 
ing. A  penetrating  wound  is  one  which  opens  into  the  pleural  cavity 
or  mediastinum.  Pneumothorax,  with  haemorrhage  into  the  pleural  sac, 
may  occur,  however,  without  an  external  opening,  as  when,  after  a  con- 
tusion of  the  chest  a  rib  is  fractured,  causing  rupture  of  the  intercostal 
artery  and  penetration  of  the  lung. 

Contused  wounds  of  the  chest  may  be  accompanied  by  fractiire  of  the 
ribs,  lacerations  of  the  muscles,  or  followed  by  pleuritis  with  or  without 
either  of  the  above  com])lications. 

Non-penetrating  wounds  of  the  chest,  whether  incised,  lacerated,  or 
punctured,  are  treated  as  directed  for  such  lesions  in  other  parts  of  the 
body.  The  same  may  be  said  of  gunshot-wounds  which  do  not  involve 
the  bony  framework  of  the  thorax  or  pass  into  the  cavities. 

Penetrating  wounds  of  the  thorax  are  dangerous  in  proportion  to  the 
size  of  the  entering  substance,  the  direction  and  dej^th  of  the  track  of 
the  wound. 

Punctured  wounds,  not  involving  the  heart  and  great  vessels,  are  not 
iisually  fatal,  while  death  is  apt  to  follow  even  small  lesions  of  these 
organs.  Incised  wounds  are  more  dangerous,  while  ^w/^sZ/o/'-wounds  are 
still  graver  lesions. 

Passing  in  any  direction  into  or  through  the  mediastinum,  a  gunshot- 
wound  is  apt  to  inflict  fatal  violence.  In  the  lungs  and  pleura;  the  prog- 
nosis is  not  so  grave,  being  xn-oportionate  to  the  size  of  the  missile  and 
to  the  nearness  of  its  approach  to  the  great  vessels  at  the  root  of  the 
lung. 

Again,  if  a  rib  is  fractured  at  the  jioint  of  entrance,  the  gravity  of 
the  prognosis  is  increased  from  the  lodgment  of  particles  of  bone  driven 
into  the  bmg.  Wounds  produced  by  missiles  of  small  caliber,  not  fatal 
within  a  few  hours,  ai'e  apt  to  end  in  recovery. 


476  A  TEXT-BOOK   ON   SURGERY. 

Diagnosis. — Penetrating  wounds  of  the  chest,  involving  the  lung,  are 
accompanied  almost  always  by  bleeding  from  the  month,  dyspnoea,  and 
by  the  passage  of  air  in  and  out  through  the  wound  with  each  respira- 
tory act.  The  dyspnoea  is  due  to  blood  in  the  bronchial  tubes  and 
trachea,  and  often  to  partial  collapse  of  the  lung,  which  is  caused  by  the 
entrance  of  air  through  the  wall  of  the  thorax. 

The  admission  of  air  to  the  pleural  sac  does  not,  however,  always 
follow  a  penetrating  wound,  on  account  of  its  small  size  or  the  valvular 
arrangement  of  the  tissues  through  which  it  passes. 

Shock  is  usually  profound  if  the  lung  is  wounded.  A  wound  of  en- 
trance and  exit,  with  the  pleura  and  lung  directly  between,  indicates 
lesion  of  these  organs.  Occasionally,  however,  a  ball  strikes  against  a  rib, 
is  deflected,  and  sweeps  around  the  chest  beneath  the  skin  and  makes  its 
exit  at  a  remote  point  without  entering  the  pleural  cavity. 

Treatment. — The  arrest  of  haemorrhage  is  the  immediate  indication. 
This  may  be  hastened  by  deligation  of  the  extremities,  already  described 
on  page  74. 

Any  bleeding  from  the  vessels  of  the  thoracic  wall  should  be  arrested 
by  the  ligature.  Foreign  bodies,  fragments  of  bone,  etc.,  near  the  wound 
of  entrance  or  exit,  should  be  removed.  When  hernia  of  the  lung  occurs, 
if  seen  before  strangulation  has  taken  place,  it  should  be  irrigated  with 
l-to-5000  sublimate  solution  and  reduced.  If  gangrenous,  the  protruding 
mass  should  be  tied  with  the  elastic  ligature  and  the  dead  portion  re- 
moved. 

Uncom])licated  wounds  of  small  size  should  be  closed  at  once  by  an 
iodoform  and  sublimate  gauze  dressing,  well  applied.  If  symptoms  of 
empyema  follow,  an  opening  may  be  made  for  drainage,  provided  that 
the  presence  of  pus  is  demonstrated  by  the  aspirator. 

In  complicated  wounds,  where  the  opening  is  large,  or  where  frag- 
ments of  bone,  clothing,  or  any  foreign  substance  has  been  driven  into 
the  pleura  and  lung,  it  should  be  kept  open  for  drainage  and  treated  by 
in-igation,  as  directed  for  empyema. 

In  wo/inds  of  tlie  heart  the  right  auricle  and  ventricle  are  most  fre- 
quently injured.  Punctured  wounds  are  less  apt  to  prove  fatal  than 
those  produced  by  gun-missiles.  Fischer  has  collected  four  hundred  and 
fifty-two  cases  of  wounds  of  the  heart,  with  seventy-two  recoveries.* 

The  symptoms  of  injury  to  the  heart  are  those  of  profound  shock. 
The  pulse  is  irregular,  and,  if  there  is  haemorrhage  into  the  pericardium 
and  mediastinum,  symptoms  of  pressure  on  the  heart-muscle  are  soon 
evident. 

The  means  employed  to  arrest  internal  haemorrhage  elsewhere  may  be 
used  here.     Quiet  should  be  enforced. 

*  "  Arcliiv  fur  kliuische  Clnrurgie,"  1868. 


CHAPTEK  XVII. 

THE   ABDOMEN. 

Tlie  F>tomaoli. — Gadrostomy*  which  operation  has  been  described  in 
the  article  on  oesoiahageal  stricture,  is  required  occasionally  in  the  removal 
of  foreign  bodies  which  have  been  carried  into  the  stomach  and  can  not 
find  an  exit  through  the  pylorus  or  be  ejected  in  the  act  of  vomiting. 
Although  a  considerable  degree  of  tolerance  may  be  present,  if  the  size 
and  shape  of  the  foreign  body  are  such  that  the  probability  of  its  re- 
moval by  natural  means  is  remote,  the  stomach  should  be  opened. 

The  method  of  jjrocedure  is  the  saine  as  that  already  described.  Since 
the  (Esophagus  is  patent,  the  stomach  should  be  thoroughly  washed  out 
with  warm  water  introduced  by  means  of  the  cesophageal  tube  and  the 
pump.  No  solid  food  should  be  allowed  within  twelve  hours  of  the 
Incision  into  the  wall  of  this  organ.  This  double  precaution  will  pre- 
vent the  otherwise  possible  escape  of  ingested  matter  into  the  peritoneal 
cavity.  The  stomach  should  not  be  opened  nntil  it  has  been  securely 
stitched  to  the  edges  of  the  wound  in  the  abdominal  wall,  as  heretofore 
directed.  The  foreign  body  may  be  felt  vrith  the  finger  and  extracted 
with  a  pair  of  dressing-forceps.  The  opening  should  not  be  closed  at 
once,  but  allowed  to  heal  by  granulation. 

Gastrostomy  may  also  be  justifiable  in  certain  cases  of  stricture  of 
the  pylorus,  in  which  at  least  temporary  benefit  may  be  obtained,  by 
dilatation  of  the  stricture  by  the  finger  introduced  through  the  stomach, 
or  by  mechanical  means  used  in  the  same  way.  An  incision  about  five 
inches  in  length  should  be  made  from  the  apex  of  the  ensiforui  cartilage 
downward  and  to  the  right,  parallel  with  and  about  one  inch  below  the 
curve  of  the  right  costal  cartilages.  On  account  of  the  over-distention  of 
the  organ,  the  i^ylorus  may  be  farther  to  the  right  of  the  linea  alba  than 
normal.  The  incision  in  the  abdominal  wall  should  be  free  ;  the  stomach 
drawn  into  the  wound,  and  a  longitudinal  incision  fi'om  one  to  one  and 
a  half  inch  in  extent  made  on  its  anterior  wall  near  the  pylorus.  The 
finger  should  be  introduced  gradually  and  forcibly  into  the  stricture. 
If  the  stenosis  is  so  great  that  the  finger  can  not  be  used,  the  dressing- 
forceps  or  any  dilating  instrument  may  be  substituted.     After  the  dila- 

*  The  operations  of  gastrostomy  and  gastrotomy  differ  only  in  tliis,  that  the  former  is 
intended  to  be  more  or  less  permanently  used  for  the  introduction  of  nourishment,  while  the 
latter  is  either  closed  at  once  or  allowed  to  close  in  a  short  time. 


478  A  TEXT-BOOK   ON   SURGERY. 

tation  is  completed  the  incision  in  the  stomach  should  be  closed  by  Lem- 
bert's  suture.  If  the  oixTution  shall  luive  proceeded  thus  far  and  the 
pylorus  found  to  be  occluded,  or  so  nearly  closed  that  the  passage  of 
ingesta  is  impossible  and  its  dilatation  can  not  be  successfully  accom- 
plished, one  of  two  procedures  may  be  adopted :  1,  exsectlon  of  the 
pylorus ;  2,  (jastro-enterofitoin!/. 

Exsection  of  the  pylorus  (j>ylorectomy)iov  malignant  disease  involves 
almost  of  necessity  a  removal  of  a  portion  of  the  lesser  end  of  the  stom- 
ach (f/asfreefomy)  with  the  diseased  portion  of  the  duodenum.  Even  for 
intlammatory  stricture  (contractions  after  ulcer,  etc.)  siinj)le  pylorectomy 
is  scarcely  possible. 

The  operation  is  preceded  by  washing  out  the  stomach  with  warm 
water  once  a  day  for  several  days,  and  a  thorough  irrigation  just  before 
it  is  incised.  A  purgative  to  clear  oiit  the  intestinal  canal  is  scarcely 
necessary,  since,  as  a  rule,  only  licpiids  jjass  through  the  stricture.  The 
most  careful  antiseptic  details  should  be  carried  out.  Tlie  center  of  the 
incision  through  the  abdominal  wall  should  be  immediately  over  the 
recognized  position  of  the  part  to  be  excised.  If  a  neojjlasm  is  present, 
it  may  be  readily  located  by  palpation.  If  no  apjareciable  tumor  exists, 
the  pylorus  will  be  found  Just  to  the  right  of  the  median  line  about  the 
level  of  the  costal  cartilages,  curving  downward  on  the  right  side  of  the 
ensiform  appendix  (Fig.  530) ;  the  incision  should  extend  from  near  the 
appendix,  parallel  with  and  about  one  inch  from  the  border  of  the  cos- 
tal cartilages  of  the  right  side.     It  should  be  about  five  inches  in  length. 

All  lijemorrhage  should  be  arrested  before  the  parietal  layer  of  the 
peritonjeum  is  incised.  When  this  is  done,  the  finger  should  be  intro- 
duced and  the  pylorus  located  by  following  along  the  anterior  smooth 
surface  of  the  stomach,  beneath  the  overlapping  free  border  of  the  liver. 
If  it  be  discovered  that  the  incision  is  not  sufficiently  free,  a  lai'ge  Hat 
sponge  shoidd  be  placed  in  the  abdomen  between  the  edges  of  the  wound 
and  the  viscera,  to  prevent  the  escaj^e  of  blood  into  the  cavity  while  the 
opening  is  being  enlarged.  The  wound  siiould  Ije  widely  'Hlated,  the 
liver  and  gall-bladder  held  up  out  of  the  way  (care  being  taken  not  to 
wound  this  friable  and  vascular  organ),  and  the  parts  to  be  removed 
brought  into  view. 

Having  detennined  the  extent  of  stomach  and  duodenum  to  be 
removed,  these  organs  should  lie  lifted  as  far  as  possible  into  the  wound, 
and  the  omental  attachments,  on  both  curvatures,  divided  between  two 
rows  of  catgut  ligatures  as  far  as  the  line  of  excision,  and  no  farther.  As 
soon  as  the  peritoneal  attachments  are  divided,  a  fiat  sponge,  which  has 
been  taken  from  a  vessel  containing  Thiersch's  solution  warm  (boracic 
acid,  grs.  iv  ;  salicylic  acid,  gr.  j ;  water,  grs.  500),  and  squeezed  fahly 
dry,  should  be  placed  under  the  parts  to  be  excised  in  order  to  prevent 
blood  or  other  matter  from  getting  into  the  jieritoneal  cavity.  The  wall 
of  the  stomach  is  next  cut  through  in  a  transverse  direction,  and,  when 
a  sufficient  opening  has  been  made,  all  fluids  or  other  matter  should  be 
removed  by  small  soft  sponges  attached  to  holders.  Some  o])erators 
apply  a  clamx)  across  the  stomach  just  above,  and  to  the  duodenum  just 


GASTRO-PYLORECTOMY. 


479 


below  the  line  of  excision.  All  haemorrhage  should  be  arrested  as  the 
operation  proceeds.  If  a  clamp  is  not  employed,  a  silk  loop  should  be 
thrown  around  the  duodenum  to  prevent  its  slipping  downward.     When 


the  diseased  portion  is  removed,  the  wound  in  the  stomach  shoidd  be 
closed  from  the  lesser  curvature  downward,  until  the  ojiening  left  is  of 
the  same  size  as  that  in  the  divided  duodeuum.     The  materials  to  be 


480  A  TEXT-BOOK  ON   SURGERY. 

used  are  fine  iron-dyed  silk,  small  needles  half-cuivcd  and   perfectly 

round  on  section,  and  the  needle-holder. 

The  method  of  closure  is  by  the  Czerny-Lemhert  suture  (Fig.  531). 

The  first  row  are  inserted  from  the  inner  sitle,  the  needle  iiassing  only 
through  the  mucous  membrane  and  sulnnucous  tis- 
i-ue,  but  not  including  the  peritonaeum.  The  pos- 
terior half  of  the  wound  should  be  closed  first. 
The  outer  suture,  which  is  that  of  Lembert,  passes 
beneath  the  peritoneal  covering,  practically  run- 
„,    „        ,  ning  through   the   muscular  layer,   but   does   not 

Fio.  531.— The  Czprnv-Lem-  .    '^  ,        °  ,  '     ,  -,,       .       . 

bert  suture.    Tiie"  upper     pierco  the  mucous  membrane.     The  needle  is  in- 

suturc   is   Lemhert's,   the       ^       n  n  •  n       j_i  •     ^  ..i  i»  •       i 

lower  Ls  Czeniy's.  troduced  ou  one  Side  three  sixteenths  of  an  inch 

from  the  cut  edge  of  the  viscus,  and  is  made  to 
emerge  one  sixteenth  of  an  inch  from  the  margin  (passing  about  one 
eighth  of  an  inch  beneath  the  peritoneal  coat).  It  is  then  carried  to  the 
opposite  side  and  introduced  in  the  same  manner  one  sixteenth  of  an 
inch  from  the  cut  edge  and  brought  out  one  eighth  of  an  inch  farther  on. 
This  suture  should  be  repeated  every  eighth  of  an  inch.  As  fast  as  in- 
troduced the  ends  should  be  tied  together  and  intrusted  to  an  as.sistant. 
The  sutures  are  not  finally  tied  until  all  are  inserted,  and  are  then 
secured  from  above  downward. 

When  the  upper  portion  of  the  aperture  in  the  stomach  is  closed,  the 
sutures  should  be  carried  from  the  edges  of  the  remaining  aperture  across 
to  corresponding  points  upon  the  duodenum,  and,  when  the  entire  cir- 
cumference is  completed,  should  be  tied  and  cut  off  close  to  the  knot. 
After  a  careful  cleaning  of  the  peritoneal  cavity,  the  edges  of  the  peri- 
toneal layer  of  the  abdominal  wall  are  brought  together  with  catgut 
sutures,  while  silver  wire  or  strong  silk  sutures  are  carried  through  the 
integument,  muscles,  and  fascia  down  to  the  peritonfeum,  and  the  wound 
closed.  The  stomach  should  be  kept  at  i-est  for  the  first  day  or  two. 
An  enema  of  beef-tea  and  whisky  should  be  given  every  four  or  five 
hours.  From  two  to  four  ounces  of  the  former  to  3  j-ij  of  the  latter 
may  be  administered  at  each  injection.  Crushed  ice  in  moderate  quan- 
tities may  be  given  in  the  mouth.  After  two  days,  milk  and  licpiid  food 
in  small  quantities  may  be  given  by  the  mouth,  and  solid  food  by  the 
tenth  day. 

Oastro-enterostomy  is  an  operation  in  which  an  opening  is  established 
between  the  stomach  and  some  point  along  the  small  intestine,  usually 
the  upper  portion.  On  account  of  the  position  of  the  duodenum  and  its 
relations  to  the  pancreas  and  great  mesenteric  vessels,  it  can  not  be  util- 
ized. The  nearest  loop  of  the  jejunum  should  be  selected.  In  Wolfler's* 
operation  (Fig.  532)  the  stomach  was  opened  a  finger's  breadth  above  the 
attachment  of  the  gastro-colic  omentum  to  the  greater  curvature.  The 
incision  was  in  the  long  axis  of  the  organ,  and  measured  five  centime- 
tres (about  two  inches).     A  similar  incision  was  made  in  the  nearest  loop 

*  This  operation  was  performed  in  the  case  of  a  patient  in  whom  tliere  was  a  cancer  of  the 
pylorus  too  larfre  to  be  excised.  The  man  recovered  and  was  much  improved.  "Centralblatt 
fur  Chirurgie,"  Xo.  45,  1881,  p.  706. 


GASTRO-ENTEROSTOMY. 


481 


Fig.  532. — Wolfler's  operation  forgastro-enterostomy. 


of  small  intestine  opposite  to  the  mesenteric  attachment.     The  posterior 
wall  of  the  wound  in  the  intestine  was  first  stitched  to  the  corresponding 
edge  of  the  incision  in  the  stomach,  and  the  operation  completed  by 
uniting   the   anterior  walls.     Car- 
l)olized  flat  sponges  were  placed 
beneath  the  organs  during  the  op- 
eration. 

The  incision  in  the  abdominal 
wall  in  this  procedure  may  be  the 
same  as  that  for  exsection  of  the 
pylorus,  or  a  free  longitudinal  in- 
cision in  the  linea  alba  may  be  em- 
ployed. 

Exsection  of  the  pylorus  is  a 
difficult  operation,  requiring  a  most 
perfect  knowledge  of  the  anatomy 
of  the  parts  involved,  and  a  thor- 
ough drilling  in  the  practice  of  intestinal  suture  and  the  management  of 
intra-abdominal  wounds.  The  long  duration  of  the  operation,  together 
wi.;h  the  already  weak  condition  of  the  patient,  renders  a  fatal  termi- 
nation very  probable ;  and  if  done  for  malignant  disease,  and  recovery 
follow,  the  recuri'ence  of  the  neoplasm  is  almost  certain.  For  malignant 
neoplasm  it  is  scarcely  justifiable  ;  for  non-malignant  stricture  limited  in 
extent,  its  propriety  may  be  entertained. 

The  operation  of  Wolfler  {ga-^tro-enterosfomy)  is  more  simple,  requires 
less  time  in  its  execution,  and  otfers  a  better  chance  of  recovery  and  pro- 
longation of  life.  By  this  procedure  the  food  acted  upon  by  the  gastric 
juice  passes  into  the  small  intestine  and  then  meets  with  the  bile,  pan- 
creatic and  intestinal  juices. 

As  far  as  can  be  determined  by  the  study  of  a  limited  number  of 
cases,  dilatation  of  non-malignant  stricture  of  the  pylorus  is  a  justifiable 
operation.  If  the  stenosis  recurs  within  one  or  two  years,  and  if  the 
contraction  is  limited  in  extent,  the  surgeon  should  choose  between 
pylorectomy  and  gastro-enterostomy.  If  the  cause  of  the  stenosis  is 
cancer,  dilatation  can  only  produce  a  temporary  relief.  The  danger  of 
the  operation  is  practically  as  great  as  in  gastro-enterostomj-,  and  this 
last  procedure,  if  successful,  offers  the  best  hope  of  prolonging  life  and 
lessening  suffering.  When,  as  a  result  of  pyloric  stenosis,  life  is  en- 
dangered to  such  an  extent  that  operative  interference  is  determined 
upon,  the  abdominal  wall  should  be  opened  by  the  curved  incision 
above  given,  and  a  careful  examination  made.  If  malignant  disease  is 
discovered,  and  if  from  the  size  and  appearance  of  the  neoplasm  in- 
filtration of  the  neighboring  tissues  has  taken  place,  or  if  the  neoplasm 
involves  the  stomach,  necessitating  if  exsected  the  removal  of  a  portion 
of  this  organ,  exsection  should  be  abandoned  and  gastro-enterostomy 
jierformed. 

Duodenum. — Operations  upon  this  organ  must  be  chiefly  confined  to 
the  upper  portion  on  account  of  the  relations  of  the  bile  and  pancreatic 

31 


482  A  TEXT-BOOK   ON   SURGERY. 

ducts  to  the  middle  jjortion,  and  the  body  of  the  pancreas  and  great 
mesenteric  vessels  to  the  lower  third. 

Duodenostomy  has  been  performed  in  several  instances  for  the  relief 
of  stenosis  of  the  pylorus,  but  without  success.  The  incision  through 
the  abdominal  wall  is  the  same  as  in  pylorectomy.  The  oi)ening  should 
be  made  in  the  upper  portion  of  the  organ,  after  adhesions  have  been 
secured  by  stitching  the  intestine  to  the  edges  of  tiie  wound  in  the  ab- 
dominal wall,  as  in  gastrostomy.  Digital  or  instrumental  dilatation  of 
the  stricture  is  done  through  the  fistulous  opening.  The  benefit  to  be 
derived  from  this  operation  is  less  than  that  after  gastro-enterostomy  or 
dilatation  of  the  pylorus,  and  is  fully  as  dangerous. 


Obstiiuction  of  the  Alimentary  Canal  below  the  Pylorus. 

Partial  or  complete  occlusion  of  the  alimentary  canal  may  occur  from 
a  variety  of  causes,  namely:  1,  imi)acti(m  of  fecal  matter;  2,  foreign 
bodies ;  3,  intussusception  ;  4,  volvulus  ;  /),  constriction  by  bands ;  6, 
by  adhesions  ;  7,  omental  and  mesenteric  slits ;  8,  diverticula  ;  9,  neo- 
plasms ;  10,  stricture ;  11,  true  hernia. 

The  impaction  of  ingested  matter  may  occur  at  any  part  of  the  ali- 
mentary canal,  although  this  accident  occurs  in  the  great  majority  of 
cases  in  the  large  intestine.  The  coecum  and  ascending  colon  are  the 
most  common  seats  of  fecal  impaction,  the  sigmoid  flexure  next  in 
order. 

The  symptoms  upon  which  a  diagnosis  is  made  are  the  presence  of  a 
tumor  in  the  line  of  the  colon,  which  is  ncjt  painful  on  pressure,  may  be 
molded  by  firm  and  prolonged  compression,  is  movable,  has  formed 
gradually,  and  has  a  history  of  constipation.  In  the  sigmoid  colon  and 
rectum  digital  exploration  will  denK)nstrate  the  nature  of  the  mass. 
Vomiting,  tenderness,  and  shock,  so  common  in  acute  obstruction,  are 
absent,  or,  if  present,  only  occur  in  the  latter  stages  and  in  extreme 
cases. 

The  treatment  consists  in  the  repeated  injection  of  warm  water  until 
the  bulk  of  the  tumor  is  softened,  when  laxatives  may  be  given  by  the 
mouth.  The  method  of  injection  is  as  follows :  Place  the  patient  in  the 
knee-elbow  position,  or  upon  the  right  side  with  the  pelvis  elevated.  In 
this  position  the  pressure  is  in  great  jiart  taken  off  the  rectum,  and  a 
greater  degree  of  tolerance  is  obtained.  If  tenesmus  results,  a  full  hypo- 
dermic injection  of  morphia  should  be  administered.  The  fountain-irri- 
gator  is  the  best  instrument,  and  from  two  to  four  pints  or  more  may 
be  thrown  slowly  in  at  one  operation.  The  water  should  be  allowed  to 
remain  in  the  colon  as  long  as  possible.  When  the  impaction  is  near 
the  anus,  it  may  be  removed  with  the  finger  or  by  a  spoon. 

Foreign  Bodies. — Indigestible  substances  of  various  kinds,  intro- 
duced by  accident  or  intentionally,  at  times  pass  through  the  stomach 
into  the  intestinal  canal  and  become  lodged.  In  rarer  instances  they  are 
introduced  through  the  anus. 


OBSTRUCTION   OF  THE   ALIMENTARY   CANAL.  483 

Biliary  calculi  which  have  passed  through  the  common  duct  into 
the  duodenum,  or  causing  idceration  of  the  gall-bladder  and  duodenal 
wall,  enter  the  canal  in  this  manner,  may  also  cause  intestinal  occlu- 
sion. Again,  obstructi(m  has  been  caused  in  a  number  of  instances  by 
concretions  (enterolithes)  composed  of  magnesia,  iron,  or  any  inorganic 
matter  administered  for  a  long  period  of  time.  They  are  met  with  chiefly 
in  the  colon  as  a  solid  mass,  or  are  precipitated  upon  organic  and  indi- 
gestible matter  in  the  canal. 

The  symptoms  vary  with  the  suddenness  or  completeness  of  the 
obstruction,  as  well  as  with  its  location.  Sudden  occlusion  is  accom- 
panied by  pain  of  a  colicky  and  violent  character,  usually  referred  to 
the  seat  of  the  obstruction.  Shock  is  also  present  in  acute  stoppage 
of  the  canal.  Vomiting  is  an  early  and  prominent  symptom  of  occlu- 
sion of  the  small  intestine,  coming  on  at  a  much  later  period,  when 
the  colon  is  involved.  On  the  other  hand,  constipation  is  a  feature 
of  stoppage  in  the  large  intestine,  while  fecal  matter  in  varying  quan- 
tity may  continue  to  jiass  ^?er  anum  for  several  days  after  occlusion 
above  the  ileo-coecal  valve.  In  arriving  at  a  diagnosis,  palpation  and 
percussion  will  be  of  value.  The  knowledge  of  the  accident  when  a 
body  has  been  swallowed  will,  of  course,  establish  the  character  of 
the  occlusion.  Insane  or  hysterical  individuals  often  indulge  in  such 
practices.  Biliary  colic  not  infrequently  precedes  occlusion  from  cal- 
culi which  escape  by  the  common  duct,  while  tenderness  in  the  region 
of  the  liver  and  duodeniim  must  be  present  in  a  varying  degi-ee  in 
cases  of  perforation  of  the  duodenal  waU  by  large  calculi  from  the  gall- 
bladder. 

Tenderness  is  also  present  in  cases  where  delicate  sharp  objects  (pins, 
needles,  etc.)  have  passed  through  the  walls  of  the  intestine  and  are 
wandering  in  the  cavity  of  the  peritoneum  or  in  the  pelvis. 

The  treatment  which  should  be  instituted  in  obstruction  by  foreign 
bodies  will  depend  in  great  part  upon  the  symptoms  which  ensue.  If 
the  occlusion  is  complete  and  the  symptoms  are  alarming,  operative  in- 
terference should  not  be  delayed.  The  only  doubt  which  may  be  thrown 
upon  the  propriety  of  operating  is  the  presence  of  shock  or  collapse  in 
an  extreme  degree.  If  this  condition  is  present,  morphine  and  whisky 
hypodermically  should  be  administered  in  the  effort  to  bring  about  re- 
action. If  no  urgent  symptoms  follow  the  presence  of  a  foreign  body  in 
the  alimentary  canal,  expectant  measures  may  be  employed  in  the  hope 
that  it  may  pass  out  by  the  rectum.  When  a  foreign  body  has  been 
swallowed  and  has  gone  beyond  the  stomach,  and  its  shape  is  known  to 
be  such  that  it  may  cause  perforation  of  the  intestinal  wall,  or  that  the 
possibility  of  its  being  passed  through  is  remote,  it  is  the  wiser  policy 
not  to  lose  valuable  time  by  procrastination,  but  to  operate  at  once. 
When  introduced  through  the  anus  or  lodged  in  the  rectum  or  lower 
portion  of  the  sigmoid  flexure  of  the  colon,  they  may  be  removed 
through  the  natural  opening. 

Intussusception,  or  the  telescoping  of  one  part  of  the  intestinal  canal 
into  another,  may  occur  at  any  portion  of  the  bowel  (Fig.  533).     It  is 


484 


A   TEXT-BOOK   ON   SURGP^RY. 


met  \vith  iu  tlie  follo\vin<^  order  of  frecpieiicy  :  at  the  ileo-colic.  region, 
the  lower  part  of  tlie  jejunum  and  ileum,  and  the  colon. 

The  invagination  is  usually  from  above  downward  ;  in  rare  instances 
from  below  upward.     Very  exceptionally  both  conditions  exist  in  the 

same  subject.*  It  oc- 
curs in  males  more  fre- 
quently than  in  fe- 
males, and,  while  it 
may  be  met  with  at 
any  period  of  life,  it 
is  niui'h  more  common 
in  children  than  in 
adidts.  A  large  pro- 
portion of  cases  occur 
in  the  first  six  years  of 
life,  and  of  these  the 
first,  second,  and  third 
years  are  most  prolific. 
Intussusception  is 
usually  caused  by  spas- 
modic contraction  of 
a.  limited  portion  of 
the  circular  muscular 
fibers  of  the  intestinal 
wall,  whereby  this  por- 
tion, becoming  small- 
er and  firmer,  is  either 
overlapped  and  in- 
cluded by  the  i)art  im- 
mediately below,  or 
falls  into  it.  Paralysis  of  the  circular  muscle  would  produce  the  same 
condition.  It  may  result  from  the  dragging  of  a  neoplasm  developed  in 
the  wall  of  the  gut,  from  the  lodgment  of  a  foreign  body,  or  fecal  matter. 
Invagination  may  be  acute  or  chronic,  may  cause  complete  obstruc- 
tion at  once,  or  only  partially  occlude  the  intestinal  canal  during  its  en- 
tire existence.  The  character  of  the  sjonptoms  will  in  part  dei:)end  upon 
the  location  of  the  accident. 

When  the  ileum  and  ccecum  are  involved,  the  symptoms  of  obstruc- 
tion are  more  acute.  In  subacute  and  chronic  cases  the  colon  is  usually 
involved. 

The  symptoms  of  intussusception  may  be  those  of  acute  or  gradual 
obstruction,  as  the  invagination  is  acute,  subacute,  or  chronic. 

In  general,  pain  is  present,  and  is  continuous  or  spasmodic,  being 
referred  to  the  region  in  which  the  lesion  exists.  Tenderness  is  not 
present  at  first,  but  is  developed  as  the  inflammatory  changes  in  the  in- 
testine and  peritonseum  appear.     V(miiting  occurs  early  when  the  ob- 


Fio.  533. — Intnssueception  of  the  jejunum,     n,  Internal  ovlimler. 
b,  Middle  cylinder,    c,  External  cylinder.     (At'lur  Treves.) 


*  "  Intestinal  Obstruction,"  by  Frederick  Treves.     Lea,  Sons  &  Co.,  Philadelphia,  1884. 


INTUSSUSCEPTION.  485 

stniction  is  in  the  small  intestine,  and  later  when  the  large  intestine  is 
involved.  Tenesmus  exists  in  a  certain  proportion  of  cases,  and  is 
especially  apt  to  occur  in  intussusception  in  the  colon.  Fecal  matter 
may  pass  in  complete  obstruction  above  the  colon  until  the  contents  of 
the  large  intestine  are  evacuated,  and  may  persist  throughout  the  attack 
when  the  occlusion  of  the  gut  is  only  i)artial.  Mucus  and  blood  are  dis- 
charged in  those  cases  in  which  tenesmus  is  extreme. 

The  symptoms  of  shock  and  collapse  are  present  early  in  the  history 
of  a  majority  of  all  cases.  The  tumefaction  caused  by  the  invagination 
may  be  felt  through  the  abdominal  wall  or  per  rectum.  The  distention 
of  the  abdomen  is  not  great  when  the  lesion  is  in  the  jejunum  or  ileum. 
It  is  apt  to  be  present  when  the  colon  is  affected. 

The  prognosis  is  always  grave.  Death  occurs  in  70  per  cent  of  all 
cases,  being  about  equal  in  both  sexes  (Treves).  The  only  methods  of 
recovery,  if  left  to  nature,  are  accidental  reduction,  sloughing  and  elimi- 
nation of  the  invaginated  gut,  or  fecal  fistula.  Accidental  reduction 
can  only  take  place  in  the  milder  varieties  and  in  the  earlier  stages,  be- 
fore adhesions  or  strangulation  have  occurred. 

Distention  of  the  intestine  by  gas,  or  assuming  a  suitable  position, 
might  reduce  the  invagination.  Sloughing  occurs  in  a  certain  proportion 
of  cases,  the  dead  gut  being  passed  by  the  rectum.  Fecal  fistula  may 
form  in  very  exceptional  instances. 

Treatment. — The  conservative  treatment  consists  in  the  administra- 
tion of  an  anodyne  to  relieve  pain  and  sj^asm,  and  the  introduction  of 
tepid  water  in  volume  into  the  rectum  and  colon,  with  inversion  of  the 
patient,  or  the  employment  of  gas  or  air  in  a  like  manner.  If  the  lesion 
is  recent,  and  if  it  is  located  in  the  large  intestine,  this  practice  should 
be  tried.  As  it  is  often  impossible,  and  under  all  conditions  extremely 
difficult,  to  overcome  the  resistance  of  the  ileo-coecal  valve,  it  is  an  un- 
justifiable waste  of  time  to  attempt  a  reduction  by  these  measures  in  in- 
tussusception above  the  ileo-colic  junction. 

The  objections  to  this  method  of  treatment  may  be  formulated  thus : 
1.  The  administration  of  opium  masks  the  symptoms  by  dulling  sensi- 
bility, and  may  induce  a  dangerous  if  not  fatal  procrastination  of  more 
radical  and  certain  measiires.  2.  Distention  from  below  by  water,  gas, 
or  air — within  the  limit  of  safety  from  rui)ture — fails  to  reduce  an  invagi- 
nation in  which  strangulation  or  adhesions  have  occurred.  In  all  proba- 
bility only  the  mildest  forms  are  reducible  by  this  method,  even  when 
no  adhesions  exist.  3.  It  fails  in  such  a  vast  majority  of  cases  that  it 
induces  a  procrastination  in  surgical  interference,  and  of  itself  induces 
a  certain  amount  of  shock,  which  in  a  measure  detracts  from  the  prog- 
nosis after  abdominal  section. 

The  only  means  of  decreasing  the  heavy  mortality  following  intussus- 
ception is  in  abdominal  section.  It  is  important  that  the  operation  be 
not  deferred  too  long;  in  fact,  not  longer  than  the  recognition  of  the 
lesion.  Within  the  first  twenty-four  hours  the  prognosis  will  be  much 
more  favorable,  and  the  danger  of  a  fatal  termination  will  be  increased 
with  each  day  thereafter. 


486  A  TEXT-BOOK   OX   SURGERY. 

In  favor  of  al)(loiiiinal  section  it  maybe  said  :  1.  That  a  death-rate  of 
70  per  cent  in  treatment  without  operation  justifies  surgical  interference. 
2.  It  is  now  well  known  that,  in  a  patient  not  exhausted  ])y  asthenia  or 
prolonged  suffering,  exploration  of  the  abdominal  cavity  under  careful 
antiseptic  precautions  is  attended  with  little  danger,  and,  in  the  earlier 
hours  of  intestinal  obstruction,  it  does  not  add  much  to  the  gravity  of 
the  prognosis.  3.  If  recovery  by  sloughing  occurs,  stricture  of  the  in- 
testine is  always  to  be  considered  as  a  probable  sequel.  If  the  invagi- 
nation is  reduced  early,  or  if  exsection  is  practiced,  stenosis  will  rarely 
occur.  4.  In  the  rare  cases  of  recovery  by  fecal  fistula,  operative  inter- 
ference is  ultimately  demanded. 

Volvulus,  or  twisting  of  a  loop  of  intestine,  occurs  usually  in  the  sig- 
moid flexure  of  the  colon,  although  the  remaining  portions  of  the  colon, 
or  coecum  and  small  intestine,  may  be  occluded  by  this  accident.  The 
loop  may  become  twisted  upon  itself  at  its  mesenteric  attachment,  or 
one  loop  may  be  twisted  over  a  second.  The  last  variety  is  more  apt  to 
occur  in  the  ileum  and  lower  jejunum.  The  principal  cause  of  volvulus 
is  an  abnormally  long  mesentery,  allowing  unusual  freedom  of  motion  to 
the  loop  of  intestine  which  is  attached  to  it.  This  defect  may  be  congeni- 
tal or  acquired.  Constipation  and  the  habitual  distention  of  the  sigmoid 
flexure  by  fecal  matter  is  probably  the  most  frequent  caiise  of  elongation 
of  the  meso-colon  and  increased  length  of  this  part  of  the  large  intestine. 
It  occurs  more  frequently  in  men  than  in  women,  and  is  met  with  in 
adults  more  than  in  children.  When  the  conditions  are  favorable,  a  suit- 
able position  or  an  accident  in  movement  is  sufficient  to  rotate  the  loop 
on  its  axis,  causing  occlusion  by  the  weight  of  the  loop  and  mesentery 
brought  to  bear  upon  a  limited  surface.  The  symptoms  of  volvulus  are 
those  of  acute  intestinal  obstruction.  Pain  similar  to  that  of  colic  is  pres- 
ent from  the  start.  Constipation  is  the  rule,  and  indicates  the  sigmoid 
colon  as  the  seat  of  the  lesion.  Tenesmus  is  present  in  a  certain  number 
of  cases,  and  is  additional  evidence  that  the  colon  is  involved.  Disten- 
tion of  the  abdomen  to  an  extreme  degree  occurs  in  a  large  proportion 
of  cases,  developing  more  rapidly  in  volvulus  of  the  colon.  Vomiting  is 
rarely  present  until  late  in  the  history  of  the  case,  and,  when  it  appears 
early,  it  suggests  obstruction  in  the  small  intestine.  A  condition  of  shock 
more  or  less  profound  supervenes  if  relief  is  not  obtained.  Diminution 
in  the  quantity  of  urine  is  present  in  a  certain  proportion  of  cases. 

The  .prognosis  is  fatal  probably  without  exception  in  every  case  of 
complete  volvulus.  Strangulation  of  the  loop  and  enormous  distention 
of  the  part  involved  occur. 

Treatment. — If  the  symptoms  point  to  the  sigmoid  flexure  or  colon 
as  the  seat  of  the  twist,  the  introduction  of  warm  water  into  the  rectum 
is  indicated.  The  patient  should  be  placed  in  the  knee-elbow  position. 
The  introduction  should  be  made  gradually,  and  may  prove  successful 
in  recent  cases  where  adhesions  have  not  occurred,  or  where  the  disten- 
tion of  the  gut  is  not  too  great.  If  this  measure  is  not  successful  within 
a  few  hours,  abdominal  section  should  be  performed,  the  hand  inti'o- 
duced,  and  the  loop  untwisted. 


CONSTRICTION   BY  BANDS— DIVERTICULA.  487 

Constriction  hy  Bands. — Bands  of  cicatricial  tissue  resulting  from 
peritonitis  cause  intestinal  obstruction  in  a  certain  proportion  of  cases. 
This  accident  occurs  cliietly  m  adults,  about  equally  in  both  sexes,  being 
due  to  pelvic  iuHammations  in  women  and  to  typhlitis  and  traumatic 
peritonitis  in  men  (Treves).  The  bands  vary  in  length,  breadth,  and 
points  of  attachment.  The  lower  jejunum  and  ileum  are  involved  in 
almost  all  cases.  The  symptoms  are  in  general  those  of  acute  obstruc- 
tion of  the  small  intestine.  Pain  is  violent  in  the  beginning,  and  in  the 
majority  of  cases  is  referred  to  the  part  involved.  Vomiting  is  an  early 
and  persistent  symptom,  and,  as  is  common  in  obstruction  above  the 
ileo-ccBcal  valve,  is  apt  to  be  stercoraceous.  Shock  is  usually  more 
prominent  in  this  form  of  occlusion  than  in  those  heretofore  given.  The 
urine  is  diminished  in  quantity.  The  abdomen  is  not  tympanitic  as  a 
rule,  although  the  constricted  loop  may  be  greatly  distended,  and  may 
be  recognized  as  a  distinct  tumor  by  palpation  or  percussion,  or  by  vagi- 
nal or  rectal  exploration. 

The  diagnosis  must  be  made  from  the  history  of  a  former  peritonitis 
and  the  presence  of  the  symptoms  above  given.  The  prognosis  is  fatal, 
and  the  indication  for  treatment  is  early  operative  interference. 

In  addition  to  inflammatory  bands,  intestinal  occlusion  is  occasionally 
caused  by  the  pedicle  of  an  ovarian  or  uterine  tiimor,  or  the  Fallopian 
tube  maj^  act  in  the  same  manner. 

Adhesions  between  contiguous  loops  of  intestine,  resulting  from  peri- 
tonitis, may  occur  in  such  a  manner  as  to  lead  to  occlusion.  The  symp- 
toms do  not  differ  materially  from  those  just  given,  and  the  treatment 
is  the  same. 

Strcmgiilation  through  Slits  in  the  Omentum  and  Mesentery. — Occa- 
sionally a  loop  of  intestine  slips  through  an  opening  in  the  omentum  or 
mesentery,  becomes  imprisoned  and  strangulated.  The  rent  may  be  con- 
genital or  result  from  an  injury,  penetrating  or  non-penetrating.  The 
small  intestine  (ileum)  is  most  frequently  involved,  and  the  aperture  oc- 
curs as  a  rule  in  the  mesentery  of  the  last  part  of  this  organ.  Strangula- 
tion of  the  colon  in  this  manner  is  exceedingly  uncommon.  With  the 
exception  of  the  presence  of  a  tumor,  the  symptoms  are  the  same  as 
those  in  hernia  of  the  small  intestine  with  strangulation.  Early  opera- 
tive interference  offers  the  only  h()i)e  of  relief. 

Constriction  by  Diverticula. — Pouches  or  cavities  communicating 
with  or  attached  to  the  intestines  may  be  true  or  false — i.  e.,  congenital 
or  acquired.  Meckel's  diverticulum,  which  is  attached  to  the  last  two  or 
three  feet  of  the  ileum,  may  remain  patulous  and  open  at  the  umbilicus, 
or  more  frequently  it  ends  in  a  blind  extremity  which  may  be  continued 
as  a  cord  to  the  umbilicus.  When  it  exists  it  represents  the  vitelline 
duct  of  the  embryo,  in  which  the  normal  process  of  closure  and  oblitei-a- 
tion  has  not  taken  place.  The  vermifoiTn  appendix  may  also  be  classed 
with  the  true  diverticula.  False  diverticula  occur  in  both  the  small  and 
large  intestine,  being  slightly  more  common  in  the  colon.  Their  mode 
of  origin  is  not  as  yet  satisfactorily  explained.  They  are  found  to  pro- 
ject between  the  two  layers  of  peritonaeum  along  the  mesenteric  border 


488  A  TEXT-BOOK  ON  SURGERY. 

of  the  small  intestine,  and  into  the  appendices  epiploice  of  the  colon 
(Treves).  They  are  hernije  of  the  mucous  membrane  projecting  through 
an  aperture  in  the  muscular  layer. 

Constriction  and  strangulation  of  a  loop  of  intestine  by  Meckel's  di- 
verticulum are  much  more  apt  to  occur  than  by  the  false  pouches.  The 
vermiform  appendix  in  rare  instances  may  become  twisted  ui)()n  its  axis 
and  strangulated,  or  it  may  cause  the  constriction  of  a  neighboring  loop 
of  the  ileum. 

There  are  no  symptoms  peculiar  to  obstruction  from  true  or  false 
diverticula,  and  the  nature  of  the  lesion  can  only  be  discovered  by 
abdominal  section,  which  is  indicated  in  this  form  of  intestinal  occlusion. 

JSfeopJdsms. — Various  new-formations,  Ijoth  benign  and  malignant  in 
character,  may  occur  in  the  intestinal  canal  and  lead  to  obstruction  by 
projecting  into  the  lumen  of  the  gut,  or  by  pressure  from  without  or  by 
development  within  the  wall  proper,  producing  narrowing  or  stricture. 
Fibroma,  Jlhro-myovni,  and  lipoma  are  of  rare  occurrence.  Angioma 
is  also  exceptional  in  this  location.  Adenoma  is  a  more  common  form, 
developing  from  the  glandular  apparatus,  and  more  particularly  from 
the  follicles  of  Lieberkiihn  in  the  large  intestine. 

Sarcoma  and  carcinoma  are  also  met  with,  both  as  primary  and 
secondary  growths.  The  symptoms  of  obstruction  are,  as  a  rule,  gradual 
in  development,  and  the  presence  of  a  tumor  may  be  recognized  by  pal- 
pation with  the  abdominal  muscles  in  complete  relaxation.  Cancer  is 
the  most  common  of  these  new  formations,  and  is  apt  to  be  located  in 
the  colon  or  rectum.  According  to  Haussmann  and  Treves,  the  variety 
of  cancer  met  with  in  the  large  majority  of  instances  is  a  cylindrical 
epithelioma,  encephaloid  and  scirrhus  being  very  exceptional.  The 
growth  may  cause  constriction  by  extending  completely  around  the 
lumen  of  the  tube,  or,  by  developing  on  one  side,  cause  stenosis  by  its 
bulk  and  by  the  contractions  which  result.  The  diagnosis  of  cancer 
may  be  made  in  those  cases  in  which  the  disease  is  situated  in  the  rec- 
tum or  lower  portion  of  the  sigmoid  flexure  by  digital  examination  or 
by  the  aid  of  the  speculum.  Situated  higher  up,  the  presence  of  a 
tumor,  the  age  of  the  patient  (over  forty  as  a  rule),  and  the  peculiar 
cachexia,  will  aid  in  arriving  at  a  correct  diagnosis. 

Strict wre. — The  jmrtial  or  complete  occlusion  of  an  intestine,  by  cica- 
tricial contractions  following  inflanmiation  or  ulceration  of  its  mucous 
and  submucous  or  muscular  layers,  constitutes  a  true  intestinal  stricture. 
Constriction  by  peritoneal  bands,  or  the  infiltration  accompanying  can- 
cer, is  not  considered  as  stricture  proper. 

Any  disease  which  produces  loss  of  substance  in  the  inner  layers  of 
the  wall  of  the  gut  may  produce  stricture.  The  ulcers  of  typhoid  fever, 
tuberculosis,  dysentery,  syphilis,  and  chi'onic  intestinal  catarrh,  or  those 
resulting  from  injury  by  ingested  matter,  by  traumatism,  or  the  necrosis 
following  strangulated  hernia,  are  the  chief  lesions  which  precede  true 
stricture  of  the  intestine.  Cicatrization  in  an  ulcer  which  has  its  long- 
est axis  at  a  right  angle  to  that  of  the  intestine  is  more  apt  to  lead  to 
obstruction   than  one  which  has  its  long  axis  in  an  opposite  direc- 


ABDOMINAL  SECTION   FOR  INTESTINAL   OCCLUSION.       489 

tion.  Stricture  occurs  in  adults,  of  forty  years  or  more,  oftener  than 
in  the  young,  being  rarely  met  with  in  children  under  ten  years  of  age. 
Women  suffer  from  this  lesion  in  a  far  greater  proportion  than  men. 
No  portion  of  the  alimentary  canal,  from  the  pylorus  to  the  anus,  is 
exempt,  yet  stricture  of  the  duodenum  and  upper  jejunum  is  compara- 
tively rare  ;  the  ileum,  near  the  coDcum,  is  more  frequently  attacked, 
while  the  large  intestine,  and  especially  the  sigmoid  flexure  and  rectum, 
is  the  most  common  seat  of  this  grave  and  painful  affection. 

The  symptoms  of  stricture  are  those  of  progressive  narrowing  of  the 
intestine.  The  intensity  of  the  symptoms  will  be  proportionate  to  the 
rapidity  with  which  stenosis  results  and  to  the  portion  of  the  canal  in- 
volved. Pain  is  not  marked  until  the  narrowing  has  arrived  at  a  point 
where  ingested  matter  jjasses  through  with  difficulty.  It  is  spasmodic 
in  character,  and  occurs  at  varying  intervals.  Distention  of  the  intes- 
tine above  the  seat  of  stricture,  with  consequent  hypertrophy  of  the  wall, 
follows  sooner  or  later  in  all  cases.  The  continued  ii-ritation  of  the  bowel 
from  the  pressure  of  fecal  matter  induces  ulceration  of  the  mucous  and 
submucous  tissues  at  and  above  the  seat  of  stenosis,  and  perforation 
may  occur. 

Vomiting  is  an  earlier  symptom  in  stricture  of  the  ileum  and  jejunum 
than  when  the  colon  is  involved.  There  may  be  diarrhoea  or  constipa- 
tion, or  these  conditions  may  alternate,  and  are  therefore  of  no  diagnos- 
tic value.  Tenesmus  is  rare,  and  tlie  abdomen  is  not  distended  except 
in  case  of  peritonitis.  As  far  as  the  previous  histoiy  may  be  of  value 
in  locating  the  seat  of  the  lesion,  it  is  known  that  dysenteric  ulcers  are 
usually  found  in  the  rectum,  sigmoid  flexure,  and  coecum,  and  in  the 
order  of  frequency  in  which  these  organs  are  given ;  typhoid  ulcers 
(which  rarely  cause  stricture)  in  the  lower  ileum  and  coecum  ;  those  of 
chronic  catarrh  in  the  colon  ;  syphilis  (gumma)  in  the  rectum  and  ileum  ; 
and  tubercular  ulcers  in  the  lower  ileum  (Treves). 

The  diagnosis  of  stricture  must  be  based  upon  a  study  of  the  symp- 
toms above  given,  except  the  cases  in  which  the  lesion  is  in  the  rectum 
or  lower  part  of  the  sigmoid  flexure,  where  digital  or  instrumental  ex- 
ploration may  be  made. 

Treatment. — Stricture  of  the  rectum  and  lower  part  of  the  sigmoid 
flexure  of  the  colon  should  be  treated  by  dilatation  or  division.  Above 
this  point  the  only  hope  of  cure  is  by  exsection  of  the  part  involved. 
Enterostomy  and  colostomy  are  palliative  surgical  measures. 


Abdominal  Section  for  Intestinal  Occlusion. 

In  all  lesions  of  the  small  intestines  and  of  the  transverse  colon  in 
which  it  becomes  necessary  to  invade  the  abdominal  cavity,  the  incis- 
ion should  be  made  in  the  linea  alha,  between  the  umbilicus  and  the 
symphysis  pubis.  When  the  seat  of  the  obstruction  can  not  be  deter- 
mined without  exploration,  the  same  incisicm  should  be  practiced.  The 
coecum,  ascending  and  descending  colon,  can  be  more  directly  approached 


490  A   TKXT-BOOK   ON   SURGERY. 

from  an  opening  in  the  lateral  aspects  of  the  abdomen  immediately  over 
these  viscera.  The  sigmoid  flexure  and  upper  portion  of  the  rectum 
may  be  well  exposed  by  the  median  incision  when  the  small  intestines 
and  mesentery  are  lifted  to  one  side.  In  general,  it  may  be  said  that 
the  smaller  the  incision  the  better,  yet  the  opening  should  always  be 
sufficient  to  admit  of  thorough  exploration,  and,  if  necessary,  large 
enough  for  inspection.  The  patient  should  rest  upon  the  back,  with 
the  head  and  shoulders  .slightly  elevated,  in  order  to  relax  the  abdomi- 
nal muscles.  Strict  attention  should  be  paid  to  the  antiseptic  details 
already  given.  An  effort  should  be  made  to  strike  the  median  line  so 
exactly  that  the  incision  \vi\\  pass  between  the  two  recti  muscles.  All 
bleeding  should  be  arrested  before  the  parietal  peritoneum  is  incised. 
This  should  be  punctured,  and  a  very  dull-pointed,  grooved  director  in- 
serted, and  the  peritonanim  divided  on  this  instmnient.  The  ojjening 
should  be  at  least  four  inches  in  length.  As  .so(m  as  this  is  accom- 
plished, the  hand,  disinfected  in  sublimate  solution,  and  afterward  in 
Thiersch's  solution,  should  be  introduced  and  the  seat  of  obstruction 
sought.  The  escape  of  intestines  or  omentum  through  the  wound  should 
be  prevented  by  holding  large  flat  sponges  over  these  viscera  and  press- 
ing them  back  into  the  peritoneal  cavity.  All  sponges,  towels,  etc., 
brought  in  contact  with  the  viscera  should  be  disinfected  in  Thiersch's 
solution,  since  the  ordinary  sublimate  solutions  are  too  irritating.  If, 
upon  exposing  the  small  intestines,  some  of  the  coils  are  found  to  be 
greatly  distended  while  others  are  coUapsed,  it  is  pretty  safe  to  conclude 
that  the  obstruction  is  near  at  hand,  and  the  collai^sed  loops  should  be 
carefully  passed  between  the  fingers  up  to  the  obstruction.  It  is  scarcely 
possible,  in  the  condition  in  which  the  viscera  will  be  found,  to  determine 
exactly  which  is  the  upward  or  downward  direction  of  the  coils,  and  it 
may  be  necessary  to  begin  at  the  coecum  and  work  upward. 

If  the  coils  which  present  are  so  enonnously  distended  that  they  in- 
terfere with  the  exploration,  the  gas  should  be  evacuated  by  multiple 
puncture  with  the  finest  hypodennic  needle.  The  gas  escapes  through 
the  needle,  the  hole  made  by  which  is  so  delicate  that  it  is  closed  by 
contraction  of  the  muscular  fibers  of  the  gut. 

If  the  ccpcum  is  found  to  be  distended,  the  lesion  is  evidently  in  the 
colon,  and  this  organ  should  be  followed  to  the  obstruction.  If  biliary 
calculi,  a  foreign  body,  or  enterolithes  are  found,  the  part  involved  in 
the  obstruction  should  if  possible  be  brought  out  at  the  wound,  protected 
by  warm  Thiersch  towels,  the  escape  of  matter  into  the  cavity  of  the 
peritonaeum  prevented  by  flat  sponges,  and  the  body  removed  by  an 
incision  in  the  long  axis  of  the  gut,  and,  when  possible,  opposite  the 
mesenteric  attachment.  The  length  of  the  opening  should  be  sufficient 
to  aUow  of  the  removal  of  the  body  without  bruising  or  tearing.  If  the 
part  can  not  be  brought  out,  it  should  be  laid  upon  a  flat  sponge  and  the 
peritoneum  in  this  way  protected  from  the  escape  of  fecal  contents.  This 
accident  may  be  in  great  part  prevented  by  compression  of  the  gut 
above  the  obstruction.  The  wound  in  the  intestinal  wall  is  next  closed 
by  Lembert's  suture. 


ABDOMINAL   SECTION   FOR  INTESTINAL   OCCLUSION.       491 

Wlien  intussusception  exists,  the  invaginated  portion  should  be 
brought  into  full  view,  and  careful  traction  employed  in  the  effort  at 
reduction.  If  this  can  not  be  accomplished,  or  if  strangulation  and 
necrosis  exist,  exsection  of  the  necrosed  portion  should  be  made  at  once 
— if  the  condition  of  the  patient  is  sxich  as  to  justify  a  prolonged  opera- 
tion. If  not,  the  dead  loop  or  portion  should  be  brought  out  at  the 
incision  in  the  abdomen,  cut  away,  and  a  fecal  tistula  established.  The 
restoi-ation  of  the  intestinal  canal  may  be  accomplished  at  a  subsequent 
operation.  If  the  operation  has  not  been  too  long  postponed,  it  will  be 
advisable  to  proceed  with  the  exsection  at  once. 

Exsection — or,  as  it  is  sometimes  called,  resection — of  the  intestine  is 
a  very  proper  operation,  and  one  which,  when  performed  early  enough, 
with  the  careful  attention  to  details  it  requires,  will  succeed  in  the  ma- 
jority of  cases. 

The  part  to  be  removed  should,  if  possible,  be  brought  out  at  the 
abdominal  incision,  and  protected  as  advised  above.  The  same  precau- 
tions should  be  observed  to  prevent  the  contents  of  the  intestine  from 
escaping  into  the  cavity  of  the  peritongeum.  At  a  distance  of  about  one 
inch  from  the  lines  of  section  occlude  the  gut  by  a  broad  tape  ligature, 
or,  preferably,  by  a  soft,  rubber-tipped  clamp.  A  triangular  piece  of  the 
mesentery,  the  base  of  which  corresponds  exactly  to  the  portion  of  intes- 
tine which  is  to  be  exsected,  should  be  removed  with  the  gut.  The  apex 
of  the  triangle  should  extend  above  the  intestine  far  enough  to  prevent 
too  great  knotting  of  the  mesentery  and  kinking  of  the  gut  after  the 
ends  are  stitched  together.  The  vessels  should  be  seciired  by  fine  catgut 
ligatures  before  being  divided.  The  line  of  section  of  the  intestine  should 
be  through  sound  tissue,  and  sqiaarely  across  the  long  axis  of  the  gut. 
The  edges  of  the  divided  mesentery  should  be  first  stitched  together  with 
silk  sutures.  In  uniting  the  ends  of  the  intestine  the  inner  row  of  sutures 
(Czerny's),  through  the  mucous  and  submucous  tissues,  should  be  first 
inserted  and  tied,  and  the  outer  row  (Lembert's)  afterward.*  The  for- 
mer should  be  about  three  sixteenths  of  an  inch  apart,  and  the  latter 
one  eighth  of  an  inch  distant  from  each  other.  Especial  care  should  be 
exercised  at  the  point  where  the  mesenteric  attachments  of  the  two  ends 
come  in  contact,  and  one  or  two  extra  sutures  should  be  applied  here. 
The  clamp  or  ligatures  are  now  removed,  the  loop  carefully  cleansed  in 
Thiersch's  solution,  and  returned  into  the  abdomen.  The  peritoneal 
cavity  should  always  be  cleansed  with  sponges  moistened  in  this  solution 
before  the  wound  in  the  abdomen  is  closed. 

*  In  a  ease  of  resection  of  the  small  intestine,  performed  by  Dr.  R.  S.  Sutton,  of  Pitts- 
burg, Pa.,  a  raodifieation  of  Lembert's  suture  was  employed.  Upon  one  side  the  needle  was 
introduced  through  the  peritoneal  hiyer  one  eighth  of  an  inch  from  the  edge  of  the  incision, 
passed  between  the  muscular  and  mucous  layers,  and  emerged  between  these  on  the  free  bor- 
der of  the  divided  intestine.  It  was  tlien  cnrried  across  to  the  opposite  side,  introduced 
between  the  mucous  and  muscular  coats,  and  brought  out  through  the  peritoneal  layer  one 
eighth  of  an  inch  from  the  cut  edge.  By  the  courtesy  of  a  colleague  who  did  a  laparotomy 
on  this  same  patient  several  years  later,  I  had  the  privilege  of  inspecting  the  line  of  union 
after  the  resection.  The  ends  were  firmly  united,  and  there  was  scarcely  any  diminution  in 
the  caliber  of  the  intestine. 


492  A  TEXT-BOOK  ON  SURGERY. 

Exsection  of  tlie  colon  is  somewhat  more  difficult  than  the  operation 
upon  the  small  intestine,  on  account  of  its  irregularity  in  size  and  the 
deeper  location  of  all  of  this  organ  except  the  transverse  ]iorti(m.  It 
should  be  brought  into  or  out  of  the  incision  if  possible,  or,  if  this  can 
not  be  done,  the  opening  in  the  linea  alba  may  be  enlarged  in  the  direc- 
tion best  suited  to  the  case.  If,  after  exploration  through  an  incision  in 
the  linea  alba,  the  obstruction  is  found  to  be  in  the  cfficum,  ascending  or 
descending  colon,  and  the  part  involved  is  so  lirmly  fixed  that  it  can 
neither  be  brought  into  view  through  the  wound  in  the  median  line  nor 
by  an  additional  transverse  incision  of  two  or  three  inches,  it  will  be 
advisable  to  close  this  opening  and  expose  the  part  by  an  incision  imme- 
diately over  it. 

Fecal  fistula  is  established  by  bringing  the  loop  or  portion  of  intes- 
tine which  is  involved  in  the  obstruction  into  the  wound  and  stitching  it 
to  the  edges  of  the  incision  as  directed  in  gastrostomy.  Strangulated 
and  necrotic  portions  should  be  cut  away. 

If  the  obstruction  is  due  to  volvulus,  it  will  be  indicated  by  unusual 
distention  of  the  twisted  loop,  which,  in  case  the  sigmoid  flexure  is 
involved,  is  enormous.  An  effort  should  be  made  to  untwist  the  gut 
without  puncture ;  but  if  this  can  not  be  accomplished,  the  hypodermic 
needle  should  be  employed  as  above  directed.  In  case  of  gangrene  or 
adhesions  amounting  to  stricttire  at  the  point  of  crossing  of  the  two  por- 
tions of  the  gut,  the  operation  of  exsection  or  for  fecal  flstula  should  be 
done. 

"When  the  constriction  is  caused  by  peritoneal  bands,  these  should  be 
divided  and  the  intestine  liberated.  If  a  loop  of  intestine  has  been 
caught  beneath  the  pedicle  of  a  tumor  (of  the  ovary,  uterus.  Fallopian 
tubes,  etc.),  the  occlusion  may  be  relieved  with  or  without  removal  of 
the  offending  body. 

In  adhesions  of  the  contiguous  peritoneal  surfaces  of  a  loop  of  intes- 
tine, or  the  matting  together  of  several  loops  in  siu^h  a  manner  that 
obstruction  occurs,  exsection  or  the  formation  of  a  fecal  fistula  is  indi- 
cated. If  the  adhesions  are  limited,  they  may  be  dissected  apart ;  but 
this  procedure  is  not  unattended  with  danger  from  sloughing  or  a  recur- 
rence of  the  lesion. 

Strangulation  or  constriction  of  a  loop  of  gut  in  a  slit  of  the  mesen- 
tery or  omentum  should  be  treated  by  enlarging  the  slit,  reduction  of 
the  loop,  and  closure  of  the  opening  by  catgut  sutures.  If  necrosis  has 
resulted,  exsection  or  the  formation  of  a  fistula  may  be  done.  In  limited 
necrosis  the  dead  portion  may  be  cut  away  and  the  hole  closed  by  Lem- 
bert's  suture,  provided  that  the  lumen  of  the  gut  is  not  too  gi-eatly 
occluded  by  this  operation,  and  always  provided  that  the  margins 
through  which  the  sutures  pass  are  sound. 

Intestinal  obstruction  due  to  diverticula  should  be  treated  by  division 
of  the  constricting  tissues.  A  false  diverticulum  can  scarcely  be  removed 
with  safety,  but,  if  necessary,  Meckel's  diverticulum  or  the  vermiform 
appendix  may  be  excised.  In  closing  the  stump  of  the  appendix,  the 
peritoneal  coat  should  be  turned  in  by  Lembert's  suture. 


HERNIA.  493 

The  removal  of  neoplasms  may  require  the  exsection  of  a  part  of  the 
intestinal  canal.  In  general,  the  rules  above  laid  down  are  applicable 
here.  Cylindrical  epitheliomata,  with  no  infiltration  of  the  neighboring 
lymphatics  or  mesentery,  are  included  among  neoplasms  which  may 
with  propriety  be  excised.  When,  however,  the  extent  of  the  infiltra- 
tion is  such  that  a  complete  removal  is  improbable,  the  palliative  ojiera- 
tion  of  forming  a  fistula  is  advisable. 

Stricture  of  the  intestine  above  the  rectum  may  be  excised  in  favor- 
able cases,  or  life  may  be  prolonged  by  establishing  an  artificial  opening 
in  the  gut  above  the  seat  of  occlusion.  Exsection  will  afford  a  more 
satisfactory  result  in  the  majority  of  instances  when  undertaken  before 
the  patient  is  exhausted  by  inanition  and  prolonged  suffering. 

When  the  obstruction  is  located  in  the  lower  portion  of  the  ileum  or 
in  the  first  part  of  the  colon,  ileo-colostomy  may  be  performed  when 
exsection,  in  order  to  be  successful,  mnst  be  an  extensive  procedure.  In 
this  operation  tiie  end  of  the  ileum  is  stitched  to  the  margins  of  a  suitable 
opening  in  the  colon  below  the  obstruction.  It  is  analogous  to  gastro- 
enterostomy. 

Hernia. — Literally  defined,  a  hernia  is  a  tumor  formed  by  the  escape 
of  the  whole  or  a  portion  of  any  viscus  from  its  normal  cavity.  The  tenn 
is  now  by  common  consent  almost  wholly  restricted  to  protrusions  of 
intestine  or  omentum  (or  both)  from  the  cavity  of  the  abdomen  or  pelvis. 
The  protrusion  may  occur  through  an  opening  which  is  congenital  or 
acquired.  Complete  inguinal  hernia  following  the  descent  of  a  testicle, 
or  ventral  hernia,  due  to  failure  of  perfect  union  in  the  aponeuroses  of 
the  abdominal  miiscles,  are  instances  of  the  former ;  while  a  protrusion 
of  the  intestine  after  a  wound  in  the  abdominal  wall  is  an  example  of 
the  latter.  The  hernia  may  take  place  into  an  adjoining  cavity,  as  the 
thorax  (diaphragmatic),  or  protrude  beneath  the  skin  (femoi-al,  umbilical, 
ventral,  etc.). 

ITernise  are  classified  according  to  their  place  of  esca])e :  inguinal, 
femoral,  umbilical,  ventral,  diaphragmatic,  gluteal,  obturator,  lumbar, 
and  vaginal.  The  term  ventral  is  applied  to  aU  herniee  occurring  at 
points  on  the  alidominal  wall  other  than  those  indicated  in  the  classifi- 
cation just  given.  Of  hernijK?  in  general  the  inguinal  variety  forms  about 
80  per  cent  of  all  cases ;  femoral,  10 ;  umbilical,  5 ;  the  remaining  vari- 
eties, 5.     Of  every  five  patients  affected  with  liernia  four  are  males. 

Inguinal  hernia  in  males  occurs  more  often  in  the  first  ten  years  of 
life  than  in  any  subsequent  decade,  the  period  from  the  twentieth  to 
the  fortieth  year  being  next  in  order  of  frequency.  According  to  King- 
don,  femoral  hernia  in  males  of  all  ages  is  met  with  in  4  of  every  100 
cases ;  in  the  first  decade,  in  1  of  every  300  ;  the  second,  2  per  cent ;  the 
tliird  and  fourth  together,  4|-  per  cent ;  the  fifth  and  sixth,  6  per  cent ; 
and  after  this,  8  per  cent. 

In  females,  inguinal  and  femoral  hernise  are  met  with  in  about  equal 
proi)ortions.  The  latter  variety  is  rarely  met  with  befoi'e  puberty,  but 
occurs  chiefly  during  the  child-bearing  period  (Bryant). 

The  contents  of  a  hernia  are  inclosed  in  a  sac  almost  always  fonned 

32 


494 


A  TEXT-BOOK   ON  SURGERY. 


by  the  perironiciiiu  lining  the  ut)(h)niinal  cavity.  The  sac  may  be  car- 
ried immediately  in  front  of  the  escaping  intestine  or  omentum  (femoral, 
umbilical,  etc.),  or  these  viscera  may  descend  into  a  sac  already  formed 
by  the  escajie  of  S(mie  other  organ  (inguinal,  scrotal).  In  the  rare  cixses 
of  hernia  of  those  j^ortions  of  the  large  intestine  not  covered  by  perito- 
ngeum  there  is  no  true  sac.  If  the  intestine  alone  enters  into  the  foinia- 
tion  of  a  hernia,  it  is  called  enterocelc ;  if  omentum  alone,  (qi'rplocdc ;  if 
both  are  inclosed  in  the  sac,  enter o-epiplocele.  The  coverings  of  a  hernia 
outside  of  the  sac  will  vary  with  its  location,  and  will  be  given  in  the 
consideration  of  the  different  varieties.  A  hernia  is  said  to  be  reducible, 
when  the  contents  of  the  sac  can  by  any  means  be  rettirned  into  tlie  cav- 
ity of  the  abdomen  ;  irreducible,  when  adhesions  exist  to  such  an  extent 
that  this  can  not  bo  effected  ;  sfra/u/ulated,  when  the  circulation  in  the 
tumor  is  arrested  by  constriction  at  any  portion  (^usually  at  the  neck). 


Jb'TG.  534.— The  relations  of  the  points  of  escape  of  oblique  and  dirert  iiitrninal  anJ  obturator  heraiffi  to  the 
important  vessels  of  tbe  pelvis.  1,  Internal  abdominal  riuix.  2/  Point  at  nhieh  a  direct  inguinal 
hernia  commences.     3,  Obturator  canal,  arte-ry,  and  nerve.     (Modified  from  Maclise.J 


Special  HernicB,  Inguinal. — An  inguinal  hernia  may  be  direct  or 
indirect,  complete  or  incomplete,  congenital  or  acquired. 

The  indirect  or  "oblique"  variety  is  much  more  frequently  met  with. 
In  tlie  male  the  contents  pass  into  the  internal  abdominal  ring  and  follow 


INGUINAL   HERNIA. 


495 


the  spermatic  cord  along  the  inguinal  canal,  at  times  descending  into  the 
tunica  vaginalis  testis.  In  tlie  female  the  descent  is  in  the  canal  of 
Nuck,  following  the  round  ligament  into  the  inguinal  canal,  and  at  times 
as  far  as  the  labium.  The  epigastric  vessels  are  internal  to  the  neck, 
and  behind  the  body  of  an  oblique  inguinal  hernia  (Figs.  534  and  546). 


Fig.  535. — Showing,  at  1  and  2,  openinss  at  which  oblique  and  direct  herniae  escape,  and  their  relations 
to  the  deep  epigastric  artery.     ^Modified  from  Maclise.; 


A  direct  hernia  does  not  enter  the  internal  abdominal  ring,  but  pushes 
the  fascia,  which  is  to  the  inner  side  of  the  epigastric  vessels  and  imme- 
diately behind  the  external  ring,  directly  in  front  of  the  tumor  and  out 
at  the  external  ring.  The  epigastric  vessels  are  external  to  the  neck, 
and  may  be  displaced  slightly  in  front  and  to  the  outer  side  of  a  direct 
inguinal  hernia  (Figs.  535  and  545). 

An  inguinal  hernia  is  said  to  be  complete  when  the  contents  protrude 
beyond  tlie  external  ring ;  incomplete,  when  the  tun^or  is  within  this 
limit. 

A  complete  inguinal  hernia  in  the  male  may  descend  into  the  cavity 
of  the  tunica  vaginalis  testis,  the  contents  resting  in  contact  with  the 


496 


A  TEXT-BOOK   ON   SURGERY. 


Fio.  SSfi.— Confrenital  oblique  inguinal  hernia.  Sac 
fornu'd  bv  the  tunica  uapinalu  et  funiculi.  1, 
t'avitv  oi'the  tunica.     (After  Maclise.) 


Fig.  .'537.— Infantile  honiia  (acquired),  the  Intes- 
tine cnrryintj  with  it  a  process  of  pcritomeuin 
by  the  side  of  the  occluded  siieriniitic  tulie. 
(Alter  Maclise.) 


Flo.  .538.— Complete  inj,'uinal  hernia  as  it  occurs  in  the 
adult.  Not  conimunicatinor  with  the  cavity  ot  the 
tunica  vaginalis  ttstis.     (After  Maclise.) 


testicle  {congenital)  (Fig.  536) ; 
or  it  may  be  arrested  in  the 
tubular  sheath  which  surrounds 
the  spermatic  cord  {infantile), 
the  contents  not  in  contact  with, 
but  pressing  upon,  the  testicle 
(Fig.  537). 

Crt?/se.— Inguinal  hernia  may 
be  congenital  or  acquired.  A 
congenital  hernia  exists  at 
birth,  and  usually  descends 
into  the  tunica  vaginalis  testis. 
It  results  from  the  patulous 
condition  of  the  process  of 
peritoneum,  which  is  carried 
downward  in  the  descent  of 
the  testicle  and  spermatic  cord. 
Acquired  hernia  is  one  which 
comes  on  after  birth.  It  is 
caused  by  the  pressure  of  the 
intestine  or  omentum,  from 
gravity  and  muscular  effort 
combined. 

Femoral  hernia  is  always 


FEMORAL   HERNIA. 


497 


acquired.  The  tumor  enters  the  crural  canal  beneath  Poupart's  liga- 
ment, just  to  the  inner  side  of  the  iliac  and  femoral  vein  (Fig.  539).  If 
it  remains  in  the  crural  sheath,  it  is  an  incomplete,  but  if  it  protrudes 
at  the  saxjhenous  opening,  it  is  a  complete  femoral  hernia  (Fig.  o-lOj. 


Fig.  539. — Showing  the  femoral  rinir  and  its  relations  to  the  iliac  vein  and  the  obturator  artery  when 
derived  from  the  deuj)  epigastric.  1,  Femoral  ring.  2,  Obturator  foramen.  .3,  Deep  epigastric  artery. 
4,  .Abnormal  origin  ot  the  obturator  running  internal  to  the  neck  of  a  femoral  hernia.  5,  The  same, 
descendir.g  external  to  the  neck  of  a  femoral  hernia.  tJ,  Normal  obturator  artery.  7,  Circumflex 
branch  of  external  iliac.     (Modified  from  Maclise.) 


Umbilical  hernia  is  congenital  or  acquired.  It  exists  not  infre- 
quently at  birth  in  both  sexes,  on  account  of  the  patulous  condition  of 
the  omplialo-mesenteric  duct.  In  this  variety  the  only  covering  of  the 
tumor  is  the  sheath  of  the  umbilical  cord.  In  the  acquired  form  the 
intestine  escapes  either  directly  throiigh  the  navel,  or  more  fi-equently  to 
one  side  of  tliis  contracticm.  The  sac  of  an  acquired  umbilical  liernia 
is  composed  of  the  parietal  layer,  of  the  peritonaeum,  and  the  outer  cov- 
ering of  integument. 

Ventral  hernia  may  also  be  congenital  or  acquired.  The  protrusion 
may  occur  at  birth,  as  a  result  of  failure  of  development  in  the  muscles 
of  the  abdomen.  It  is  usually  met  with  along  the  linea  alba  above  the 
umbilicus.  The  acquired  form  may  occur  at  any  point,  and  residts  from 
accidental  or  surgical  wounds  of  the  muscles  and  fascia.  It  is  quite 
frequently  met  with  in  the  wounds  of  incision  in  the  operation  of  lapa 
rotomy. 


498 


A   TEXT-BOOK   ON   SURGERY. 


Diaphragmatic  hernia  is  usually  due  to  a  wound  or  rupture  of  the 
diaphragm.  It  may  result  from  a  congenital  defect  in  this  muscle.  It 
generally  occurs  on  the  left  side,  on  account  of  the  prdtecrion  afforded 
by  the  liver  on  the  right  side. 

Gluteal  hentia  is  extremely  rare.  The  escape  of  the  viscus  is  through 
the  sciatic  notch,  and  it  may  occur  above  or  below  the  pyriformis  muscle. 


M 

Flu.  540. — Showing'  the  relations  of  a  complete  femoral  hernia  to  the  important  organs  of  the  groin. 
1,  .Sapl)enous  vein  pa-^sinj;  beneath  the  liiloiform  process.  2,  Femoral  vein  and  artery.  3,  Crural 
nerve.    4,  Plexus  of  femoral  lymphatic  glands.     (Modified  from  Maclise.) 

Obturator  Jientia  takes  place  in  tlie  thyroid  foramen,  and  usually 
in  the  upper  portion,  in  the  canal  which  gives  exit  to  the  obturator  ves- 
sels and  nerves  (Fig.  534).     It  is  more  common  in  women  than  in  men. 

Lumbar  hernia  occurs  in  the  region  situated  between  the  twelfth 
rib  and  the  crest  of  the  ilium. 

Hernia  into  the  vagina  occurs  after  partial  or  complete  prolapse  of 
the  uterus,  or  after  loss  of  substance,  allowing  escape  of  the  intestine. 

Symptoms — Inguinal  Hernia. — AVhen  gradually  acquired,  the  pres- 
ence of  a  small  swelling  or  tumor  near  the  center  of  Poupart's  ligament, 
or  a  little  to  the  inner  side  of  this  i)oint,  is  usually  the  first  symi)tom 
of  inguinal  hernia.  In  a  certain  proportion  of  cases  the  appearance  of 
the  swelling  has  been  preceded  by  a  feeling  of  weakness  or  uneasiness 
referred  to  this  region,  which  only  disappeared  when  the  recumbent 


HERNIA. 


499 


posture  was  assumed,  or  wlien  strong  upward  pressure  was  made  by  the 
hand. 

If  suddenly  acquired,  the  presence  of  the  tumor  is  noticed  soon  after 
a  violent  strain  of  the  abd<jminal  muscles.  Pain  is  almost  always  pres- 
ent, and  the  patient  is  generally  aware  of  the  moment  the  rupture  oc- 
curred. 

The  diagnosis  of  inguinal  hernia  involves,  (1)  the  differentiation  be- 
tween the  direct  and  indirect  form,  and  (2)  between  inguinal  and  femoral 
hemijB  and  the  various  swellings  which  may  occur  in  this  region ;  vari- 
cocele, hydrocele,  bubo,  incarcerated  testicle,  new  formations,  abscess, 
and  aneurism. 

A  direct  inguinal  hernia  is  exceptional.  The  tumor  formed  by  it  is 
apt  to  be  spherical  (Fig.  541),  is  situated  nearer  the  median  line,  and 


Fig.  oil.— Direct  inguinal  hernia.     (After  Bryant.)        Fio.  542. — Oblique  inguinal  hertia.    (After  Bryant.) 


the  neck  will  be  found  to  enter  the  abdominal  cavity  immediately  be- 
hind the  external  ring. 

The  tumor  formed  by  an  oblique  inguinal  hernia  (Fig.  542)  is  oval  or 
elliptical  in  the  incomplete,  and  oval  or  ])yriforni  in  the  complete  variety. 
The  history  of  the  swelling,  if  gradually  de- 
veloped, will  indicate  that  the  tiimor  com- 
menced at  the  middle  of  Poupart's  ligament 
and  traveled  toward  the  pubes.  In  cases  of 
long  standing,  and  when  the  tumor  is  of  large 
size,  the  diagnosis  between  the  direct  and  in- 
direct form  is  scarcely  possible,  from  the  fact 
that  the  inner  edge  of  the  internal  ring  has 
been  dragged  down  until  it  occupies  a  posi- 
tion just  behind  the  external  opening. 

A  femoral  hernia  (Fig.  543)  is  situated  be- 
low Poupart's  ligament,  and  near  its  attach- 
ment to  the  spine  of  the  pubes,  to  the  inner  side  of  the  femoral  vessels. 
In  lean  subjects  the  neck  of  the  tumor  can  be  readily  traced  to  the  canal 
at  this  point.     In  corpulent  persons  the  diagnosis  is  more  difficult. 

The  swelling  of  varicocele  commences  in  the  lower  posterior  portion 
of  the  coi'd,  and  increases  gradually  upward.     To  the  touch  the  dis- 


/ 


Fig.  543. — Femoral  hernia. 
(After  Bryant.) 


500  A   TEXT-BOOK   ON   SURGERY. 

tended  veins  feel  like  worms.  The  tumor  has  none  of  the  elasticity  of 
hernia. 

In  the  r('ouml)(>iit  jiosiiiren  vniicoccle  and  a  noii-iDrnTrei-ntod  intiuinal 
hernia  will  l)()th  disappear.  II'  alter  tlie  disajipearance  linn  pressure  is 
made  with  the  fingers,  and  the  patient  is  directed  to  resume  the  ui)right 
posture,  the  varicocele  will  return,  while  the  heiiiia  can  not  descend. 
Coughing  does  not  affect  varicocele.  The  accumulation  of  tluid  in 
hydrocele  of  the  tunica  vaginalis  is  first  noticed  in  the  most  inferior 
portion  of  the  scrotum  ;  the  swelling  is  spherical  at  first,  and  becomes 
pyriform  after  the  cord  is  involved.  Hydrocele  is  translucent,  and  fiuct- 
nation  may  be  detected.  Encysted  hydrocele  of  the  cord  near  the 
external  ring  or  within  the  inguinal  canal  may  make  differentiation 
more  difficult.  The  impulse  from  coughing  is  not  marked  in  hydrocele, 
the  sense  of  weakness  is  absent,  the  cyst  is  small  and  usually  remains 
so.  If,  after  full  consideration,  doubt  still  exists,  aspiration  with  the 
finest  hypodermic  needle  will  clear  up  the  diagnosis. 

Bubo. — In  chronic  adenitis  the  glandular  character  of  the  swelling 
can  be  made  out  distinctly. 

In  acute  adenitis,  although  the  peri-lymphatic  infiltration  is  so  exten- 
sive that  the  glands  can  not  be  recognized,  the  redness  of  the  skin,  the 
great  tenderness  on  pressure,  and  the  superficial  character  of  the  pain, 
with  the  coexistence  of  a  urethritis  or  sore  upon  the  penis  or  scrotum, 
will  serve  to  establish  the  character  of  the  lesion. 

Incarcerated  testicle  may  be  suspected  if  there  is  absence  of  the 
organ  on  that  side.  If  the  testicle  is  not  extensively  atrophied,  pressure 
will  give  the  peculiar  and  characteristic  sense  of  pain  experienced  in  in- 
jury of  this  organ. 

In  neoplasms  there  is  a  history  of  progressive  development  entirely 
disassociated  from  that  of  hernia  as  heretofore  detailed. 

Abscess,  which  not  infrequently  appears  above  Poupart's  ligament, 
is  accompanied  with  inflammatory  and  septic  symptoms  which  do  not 
accompany  hernia.  Abscess  of  this  region  occurs  with  adenitis,  as  Just 
stated,  and  with  ostitis  of  the  vertebrae  or  ilium.  The  recognitum  of 
either  of  these  lesions  will  lead  to  the  diagnosis  of  abscess. 

In  the  manipulation  of  a  hernial  tumor  the  sensation  imparted  to  the 
fingers  will  vary  with  the  contents  of  the  sac  and  the  condition  of  the 
mass.  If  it  contain  only  omentum,  it  is  doughy  to  the  feel,  and  will 
yield  dullness  on  percussion  ;  if  the  mass  is  composed  of  intestine,  it  is 
elastic,  and  more  or  less  tympanitic  on  percussion.  The  "colicky" 
pain  felt  when  the  intestine  is  firmly  compressed  is  of  diagnostic  value 
in  determining  the  presence  of  a  hernia. 

Whether  a  hernia  is  reducible  or  not,  there  is  always  a  perceptible 
impulse  imparted  to  the  tumor  in  coughing  or  sneezing.  In  strangulated 
hernia  the  diagnosis  rests  first  upon  the  existence  of  a  tumor,  which  is 
present  in  almost  all  cases.  In  very  exceptional  instances  there  is  no  pro- 
trusion noticeable.  The  next  symptom  is  pain  at  the  seat  of  the  hernia. 
In  character  it  is  com])ared  to  that  of  intestinal  colic,  and,  when  not  in- 
tensified in  the  neighborhood  of  the  strangulation,  it  is  usually  referred  to 


HERNIA.  501 

the  umbilical  region.  The  symptoms  of  occlusion  are  more  remote,  and, 
while  very  strong  in  a  diagnostic  point  of  view,  are  not  of  such  impor- 
tance ijractically,  because  a  diagnosis  shoiild  be  made  and  treatment  in- 
stituted before  the  effects  of  obstruction  are  made  evident.  The  cessation 
of  fecal  discharges  may  not  occur  in  intestinal  obstruction  for  several 
days  after  the  occlusion,  when  the  small  intestine  alone  is  involved,  since 
the  contents  of  the  Ixiwel  below  the  constricted  point  may  be  evacuated. 
The  vomiting  of  recently  ingested  food  or  drinks,  followed  by  stercora- 
ceous  matter,  is  the  last  and  strongest  evidence  of  occlusion.  Distention 
of  the  abdominal  walls,  with  tympanitic  resonance,  is,  when  taken  in 
connection  with  other  symptoms,  a  sti-ong  link  in  the  chain  of  symptoms 
which  make  the  diagnosis  conclusive.  Hiccough  is  i:)resent  in  many 
cases,  but  is  apt  to  be  one  of  the  later  evidences  of  obstruction.  Shock, 
that  condition  in  which,  as  a  result  of  an  emotion  or  injury,  the  functions 
of  the  nerve-centers  are  more  or  less  completely  suspended,  is  present  in 
a  varying  degree  in  almost  all  cases  of  strangulated  hernia.  It  is  evident 
in  the  rapid  and  weak  pulse,  occasionally  missing  a  beat,  or  varying  in 
exacerbations  of  rapidity  and  slowness  ;  coldness  of  the  skin,  with  un- 
natural perspiration  ;  lack  of  facial  mobility,  the  only  expression  being 
that  of  pain  and  anxiety. 

In  omental  hernia  the  pain  is  not  so  intense  as  in  intestinal  hernia, 
and  the  symptoms  of  occlusion  are  always  absent. 

Treatment. — The  treatment  of  inguinal  hernia  may  be  considered 
under  three  heads :  1,  reducible ;  2,  irreducible  (not  strangulated) ;  3, 
strangulated. 

A  rediicihle  inguinal  hernia  should  be  returned  to  the  abdominal 
cavity  and  retained  there  by  the  constant  and  careful  employment  of  a 
truss  or  bandage  and  compress.  In  accomplishing  the  reduction  the 
patient  should  rest  upon  the  back,  with  the  thighs  flexed  ujion  the  abdo- 
men and  the  pelvis  elevated.  In  this  position  gravity  carries  the  intes- 
tine and  omentum  toward  the  diaphragm,  and  this  traction  from  within 
readily  reduces  the  mass.  If  this  should  not  succeed,  gentle  jDressure 
with  the  hand  will  suffice.  Once  reduced,  an  effort  should  be  made  to 
prevent  a  recurrence. 

For  incomplete  or  slight  hernia  in  patients  who  are  not  compelled 
to  do  heavy  work,  the  elastic  truss  is  most  comfortable  and  safe.  In 
all  other  cases  the  steel-spring  truss  must  be  worn.  The  i)ad  will  vary 
in  size  as  the  character  of  the  rupture  may  require.  The  hard-rubber 
or  wooden  pads  ai'e  preferable  in  the  gi'eat  majority  of  cases.  A  truss 
should  be  applied  before  leaving  the  recumbent  posture,  and  should  not 
be  removed  again  until  this  posture  is  resumed.  When  ordering  a  steel- 
spring  truss  the  following  rule  should  be  observed :  Describe  fully  the 
character  of  the  hernia.  If  the  case  is  one  of  complete  oblique  inguinal 
hernia  of  the  left  side,  take  a  lead-tape,  lay  one  end  directly  over  the 
internal  ring  of  this  side  and  carry  the  tape  aci-oss  the  abdomen  to  the 
right,  just  below  the  anterior  superior  spine  of  the  right  ilium,  and 
across  the  gluteal  region  back  to  the  same  point  below  the  left  sujierior 
spinous  process.     Press  the  malleable  lead  closely  to  the  integument  in 


502  A  TEXT-BOOK  ON   SURGERY. 

oixItT  to  get  :m  exact  outline  of  the  surface  to  which  tlie  truss  is  to  be 
applied,  and  trace  this  directly  upon  a  sheet  of  i)aper.  Tlie  instriini(Mit- 
niaker  in  using  this  tracing  can  model  the  s])ring  to  lit  more  comfortably, 
and  after  this  temper  the  metal  to  make  the  required  pressm-e.  When  a 
direct  and  indirect  hernial  exist  upon  the  same  side,  a  single  pad  prop- 
erly adjusted  will  suffice  to  secure  both  openings.  When  there  exists  a 
bilateral  hernia,  a  douljle  truss  should  be  worn.  A  fair  temporary  truss 
may  be  made  as  follows :  A  piece  of  cloth  or  a  tuft  of  wool,  cotton,  or 
oakum  is  rolled  into  a  compress  about  half  the  size  of  the  list,  covered 
with  adhesive  plaster  (tlie  adliesive  surface  being  external),  and  is  laid 
immediately  over  the  inguinal  canal,  after  the  hernia  has  been  reduced  ; 
and  while  the  patient  is  in  the  recumbent  posture  a  spica  bandage  is 
carried  around  the  pelvis  and  thigh  so  that  the  com])ress  is  held  tii-mly 
in  position.  It  is  prevented  from  slijjping  out  of  place  by  the  adhesive 
plaster. 

When  an  inguinal  hernia  can  not  be  retained  by  a  triiss,  operative 
interference  is  indicated.  Of  the  various  procedures  which  have  been 
introduced,  that  known  as  Ileaton's  operation  is  tlie  simi)lest  in  execu- 
tion, involves  less  danger  and  annoyance,  and  oilers  fully  as  great  a 
prospect  of  success.     It  is  performed  as  follows  : 

The  integument  within  a  radius  of  three  or  four  inches  of  the  internal 
ring  is  cleanly  shaved  and  washed  with  soap,  then  with  ether,  and,  lastly, 
mth  sublimate  solution,  1  to  2000.  The  patient  is  placed  in  the  recum- 
bent posture,  with  the  pelvis  elevated  on  pillows  until  gravity  carries  the 
intestines  away  from  the  vicinity  of  the  inner  ring.  A  syringe  made  for 
this  purpose  (Fig.  544),  having  been  tlujroughly  disinfected  by  immer- 


FiQ.  544. — Syringe  for  nciiton's  operation. 

sion  in  1  to  20  carbolic-acid  solution,  is  filled  with  nineteen  minims  of 
the  following  solution,  to  which  one  minim  of  carbolic  acid  is  added : 
Extract  of  quercus  alba,  fourteen  grains  ;  fluid  extract  of  quercus  alba, 
ludf  ounce.  Mix  over  a  hot-water  bath.  One  eighth  grain  of  sulphate 
of  morphia  may  be  added  to  each  injection.  An  anaesthetic  is  not 
required. 

The  needle  of  this  sj^ringe  is  sharp  at  the  end,  and  one  eighth  of  an 
inch  from  the  point  are  two  holes,  from  which  the  fluid  escapes.  In 
order  to  insure  the  exclusion  of  air,  the  instrument  is  held  perpendicu- 
larly and  the  i:)iston  forced  up  until  a  bead  of  the  injection-fluid  stands 
on  the  point  of  the  needle.  Being  thus  prepared,  the  operator  carries 
the  index-finger  of  the  hand  most  convenient  to  himself  into  the  canal, 
invaginating  the  skin  through  the  external  ring,  and  up  the  canal  until 
the  outlines  of  the  inner  ring  are  appreciated  by  the  finger-tip.  With 
this  finger  resting  here,  the  point  of  the  needle  is  introduced  exactly  over 
the  center  of  the  internal  ring,  and  enters  perpendicularly  to  the  plane 
of  the  abdomen  at  this  point.     When  the  impact  of  the  needle-point  is 


HERNIA.  503 

felt  by  the  tip  of  the  index-finger,  which  serves  as  a  guide  to  the  ring, 
the  finger  is  slightly  withdrawn,  so  that  the  skin,  wliirli  has  been  carried 
ahead  of  it,  may  not  be  transfixed.  Tlie  needle  is  now  in  front  of  the 
internal  ring  and  outside  of  the  peritoneum.  Pressure  is  made  upon  the 
piston,  and  about  three  minims  of  the  fiuid  expelled,  and  this  mancruvre 
is  repeated  by  carrying  the  point  of  the  needle  a  half -inch  to  the  right, 
left,  above,  and  below  this  center.  The  finger  is  now  withdrawn,  and  the 
needle  is  made  to  follow  it  down  to  the  external  ring,  discharging  the 
remainder  of  the  fluid  iii  its  track.  When  the  instrument  is  removed,  a 
pellet  of  iodoformized  gauze  is  placed  over  the  puncture,  and  over  this  a 
compress  of  sublimate  gauze,  cotton,  and  a  spica  bandage.  The  patient 
^'etains  the  dorsal  decubitus  from  ten  days  to  two  weeks,  not  even  being 
allowed  to  sit  up  in  bed.  The  i)ain  is  insignificant,  and  the  infiammatory 
process  which  supervenes  is  mild.  In  three  or  four  days  a  hard,  round, 
indurated  mass  of  embryonic  cells  will  be  found  to  occupy  the  canal  and 
tissues  immediately  adjacent.  This  generally  disapj)ears,  and  at  the  end 
of  a  month  all  ti-aces  of  the  process  will  have  disappeared.  A  truss,  with 
a  wide,  soft  pad,  should  be  worn  for  a  i:)eriod  varying  from  three  to  six 
months  after  the  operation. 

If  success  does  not  follow  the  first  attempt,  it  may  be  repeated.  The 
majority  of  cases  are  not  cured.  Incipient  hernia,  and  those  in  which 
the  canal  has  not  been  too  widely  stretched,  offer  a  better  prognosis. 
Even  when  the  canal  is  so  large  that  a  cure  can  scarcely  be  hoped  for,  it 
may  result  in  a  contraction  of  the  opening  to  such  an  extent  that  reten- 
ticm  with  a  truss  is  secured.  The  operation  for  the  radical  cure  of  ingui- 
nal hernia  by  direct  incision  will  be  given  in  the  opei-ation  for  strangu- 
lated hernia. 

Irreducible  (incarcerated)  inguinal  hernise,  not  strangulated,  under 
certain  conditions  justify  operative  interference.  If  the  patient  can  be 
kept  under  constant  supervision,  so  that  at  the  first  indication  of  strangu- 
lation proper  surgical  aid  can  be  obtained,  the  treatment  should  consist 
of  some  form  of  truss  fitted  over  the  tumor  to  prevent  the  further  pro- 
trusion of  the  intestine.  In  the  adaptation  of  such  an  apparatus,  great 
care  must  be  taken  to  avoid  compression  at  the  neck  of  the  sac,  for  in 
this  way  strangulation  might  be  precijjitated.  This  i)lan  of  treatment 
will  be  more  apt  to  prove  satisfactory  In  those  who  are  not  compelled  to 
do  heavy  labor.  In  elderly  persons  with  large  hernite,  operative  inter- 
ference is  not  justifiable  on  account  of  the  danger  it  involves. 

The  indications  for  operation  are :  1,  in  those  patients  with  small- 
sized  heniipe  who  must  of  necessity  go  upon  long  journeys,  which  take 
them  out  of  reach  of  proper  surgical  aid  in  case  of  strangulation  ;  2,  in 
those  upon  whom  a  suitable  apparatus  has  failed  to  prevent  a  further 
descent  of  intestine  ;  3,  those  who  by  reason  of  a  hernia  are  incapaci- 
tated for  work,  and  who  consent  to  the  operation  after  a  full  ex])lanation 
of  the  dangers  attending  it.  The  jirocediire  is  the  same  as  for  strangu- 
lated hernia,  although  a  much  more  fa\-orable  jirognosis  may  be  made. 

Sfrangulafed  Inguinal  Hernia. — With  the  first  symptom  of  strangu- 
lation the  patient  should  be  jjlaced  in  the  dorsal  decubitus,  with  the  foot 


504  A  TEXT-BOOK  ON   SURGERY. 

of  the  bed  elevated  about  twelve  inches,  the  pelvis  raised  upon  a  pillow, 
the  legs  flexed  on  the  thighs,  and  the  thighs  on  the  abdomen,  so  that  the 
intestines  and  omentum  will  gravitate  toward  the  diaphragm  ;  or  the 
knee-shoulder  position  may  be  assumed.  Ojjium  narcosis  should  be 
secured  at  once  to  relieve  pain  :ind  to  relax  the  muscles  of  the  abdo-' 
men.  Towels  dipped  in  hot  water  and  partially  squeezed  should  be 
laid  upon  the  tumor.  If  within  an  hour  or  two  the  hernia  is  not  re- 
duced, direct  and  careful  pressure  with  the  fingers  may  be  added.  The 
neck  of  the  tumor  should  be  grasped  and  steadied  between  the  thumb 
and  fingers  of  one  hand,  and  the  contents  pushed  gently  in  the  direc- 
tion of  the  canal  with  the  other.  Taxis  should  not  be  continued  longer 
than  five  or  ten  minutes  at  any  one  effort.  It  may  be  repeated  at  in- 
tervals of  a  half-hour  or  hour  within  the  first  six  hours  of  the  his- 
tory of  strangulation.  The  manipulation  of  a  hernial  tumor  (taxis)  after 
the  first  six  hours  of  strangulation  is  of  doubtful  propriety,  and  after 
twelve  hours  should  not  be  attempted.  It  is  not  only  to  be  condemned 
for  the  injury  intiicted  upon  the  parts  involved  by  this  procedure,  but 
on  account  of  the  procrastination  in  operative  interference  which  it 
invites.  It  is  true  that  occasionally  reduction  is  effected  after  symp- 
toms of  strangulation  lasting  for  a  longer  period  than  this,  but  these 
cases  are  so  extremely  rare,  and  the  danger  of  a  fatal  termination  so 
much  increased  by  the  delay,  that  it  will  be  wiser  to  proceed  at  once  to 
the  operation. 

In  justification  of  early  operation,  it  may  be  said  that  the  large  ma- 
jority of  cases  which  end  fatally  are  those  in  which  strangulation  has 
existed  for  from  twelve  to  twenty-four  hours  and  upward  before  surgical 
interference ;  and  that  abdominal  section  in  a  patient  not  exhausted  by 
suffering  or  disease  is  almost  free  from  danger.  The  high  rate  of  mor- 
tality after  kelotoray  will  only  be  materially  reduced  when  it  is  per- 
formed not  later  than  twelve  hours,  and,  better  still,  within  the  first  six 
hours  of  strangulation. 

Operation. — The  pubes,  scrotum,  and  integument  near  the  tumor 
should  be  shaved,  washed  with  ether,  and  finally  with  1  to  3000  subli- 
mate solution.  The  patient,  fully  anaesthetized  with  ether,  should  be 
placed  upon  a  table  nearest  the  edge  most  convenient  to  the  operator, 
with  the  pelvis  slightly  elevated.  Before  proceeding  with  the  operation, 
a  final  effort  at  reduction  should  be  made.  An  as.sistant  is  directed  to 
place  the  legs  of  the  patient  over  his  shoulders,  and  to  lift  him  until 
nothing  but  the  shoulders  and  occiput  rest  upon  the  table.  While  in 
this  position  careful  taxis  shonld  be  made.  If,  after  five  minutes,  reduc- 
tion is  not  effected,  the  attempt  should  be  abandoned.  The  parts  about 
the  field  of  oi)eration  should  be  covered  with  warm  sublimate  towels  (1 
to  3000),  leaving  a  space  about  six  by  eight  inches  uncovered. 

The  incision  should  be  in  the  long  axis  of  the  tumor,  and  may  be 
made  by  cutting  directly  down  upon  the  mass,  or  by  pinching  up  the 
skin  and  fat  immediately  over  the  swelling,  transfixing  it  and  cutting 
outward.  It  should  be  of  good  length,  with  the  center  a  little  below  the 
internal  ring.     All  bleeding  should  be  arrested  at  once  with  catgut  liga- 


HERNIA. 


505 


tures.     The  wound  should  be  irrigated  with  1  to  5000  sublimate  every 
live  or  ten  minutes. 

The  tirst  difficult  point  in  the  operation  is  the  recognition  of  the  sac. 
It  is  safe  to  cut  carefully  down  until  through  the  puncture  of  the  sac  a 
yellow  or  brownish-black  fluid  escapes.  It  is  very  exceptional  when 
there  is  not  enough  Huid  between  the  hernia  and  the  sac  to  demonstrate 
its  i^resence.  When  this  fluid  begias  to  escape,  a  grooved  director,  with 
a  very  dull  point,  is  inserted  through  the  puncture,  and  the  sac  further 


Flo.  545. — Shonins  the  relations  of  a  direct  inauinal  hernia  to  the  epigastric  vessels  and  the  spermatic 
cord.  1,  Hernial  tumor.  2.  Epiga-stric  vessels  in  IKmt  of  and  e.vtemal  to  the  neck  of  the  tumor. 
3,  Saphenous  opening  and  vein.     4,  Spermatic  vessels.     5,  Femoral  vessels.     6,  Crural  nerve. 

divided  until  the  finger  can  l)e  admitted,  when  it  is  introduced  and  the 
sac  divided  in  the  entire  extent  of  the  tumor.  At  this  stage  of  the  opera- 
tion the  contents  of  the  sac  are  clearly  in  view.  The  finger  of  the  opera- 
tor's left  hand  is  now  carried  toward  the  constriction,  palmar  surface 
upward,  and  the  nail  slipped  under  it.  Holding  the  intestine  out  of  the 
way.  a  long  probe-pointed  bistoury  is  carried  flatwise  along  the  palmar 
aspect  t)f  the  finger  until  the  didled  point  passes  between  the  sharp  edge 
of  the  ring  and  the  nail.     The  edge  is  now  turned  upward  against  the 


506 


A  TEXT-BOOK   ON    SURGERY, 


ring,  and  pressed  against  tliis  l)y  tlic  linger  upon  wliirh  it  rests.  The 
direction  of  this  cut  is  upward  and  very  slightly  inward  in  inguinal  her- 
nia. It  should  not  extend  beyond  the  eighth  of  an  inrh.  The  finger- 
nail is  usually  sufficient  to  enlarge  the  oj)ening  after  the  first  few  libers 
are  divided. 

As  soon  as  the  strangulation  is  relieved,  the  wound  and  exposed  intes- 
tine should  be  covered  in  with  towels  dipped  in  warm  Thiersch  solution, 
and  left  for  from  five  to  fifteen  minutes  in  order  to  determine  whether 
the  circulation  can  be  re-established  •  or  not.     The  cohu-  of  strangulated 


/ 


Fig.  54R.— Showing  the  relations  of  an  oblique  inL'uinal  hernia.  1,  Tumor  covered  by  cremasteric  fascia. 
2,  Episastric  vessels  behind  and  to  the  inner  side  of  the  neck  of  the  tumor.  3,  Saphenous  vein  and 
opennig.     4,  Femoral  vessels.     5,  Crural  nerve. 

intestine  varies  from  pinkish-gray  to  a  black,  motley  color.  The  con- 
tents of  a  hernial  sac  should  not  be  returned  into  the  abdomen  unless 
the  color  changes  to  a  healthy  red  after  the  strangulation  is  freely  re- 
lieved. If,  after  from  five  to  twenty  minutes,  the  circulation  is  estab- 
lished, reduction  should  be  made.  In  accomplishing  this,  posture  is 
important,  and  the  intestine  should  be  carefully  pushed  in  between  the 
thumb  and  finger.  Once  returned,  the  inner  opening  should  be  stopped 
-with  the  finger  or  a  sponge,  so  that  blood  or  the  contents  of  the  sac  or 


HERNIA.  507 

irrigating  fluid  may  not  run  into  the  peritoneal  cavity.  If  omentum  is 
contained  in  the  hernia,  it  should  be  transfixed  at  the  neck  of  the  sac 
with  a  large  doul)le  catgut  ligature,  tied  both  ways,  and  the  mass  be.vond 
the  ligature  cut  off.  The  stump  should  also  be  returned  into  the  cavity, 
never  stitched  into  the  opening.  This  accomplished,  the  sac  requires 
attention.  It  is  also  transfixed  at  the  internal  ring  with  a  large  double 
catgut  and  tied  on  both  sides  securely  ;  all  that  part  beyond  the  ligatures 
is  cut  off.  The  cut  end  of  the  sac  is  now  stitched  with  catgut  to  the 
edges  of  the  internal  ring.  In  this  operation  strong  catgut  sutures  are 
employed.  In  the  first  row  the  needle  is  made  to  transfix  the  edge  of  the 
ring,  then  through  the  sac  and  up  through  the  oppo.site  margin  of  the 
ring.  These  sutures  are  tied,  and  the  ring  tightly  closed,  so  that  the 
escape  of  fluids  into  the  peritonjeum  is  impossible.  The  last  sutures, 
which  are  of  silk  or  silver  wire,  include  all  the  tissues  from  the  skin  to 
the  deepest  portion  of  the  wound.  The  woiind  is  again  thoroughly  ind- 
gated,  and  a  Xeuber's  bone-drain  is  inserted,  so  that  the  end  leads  out 
of  the  deepest  portion.  Sublimate  gauze,  borated  cotton,  and  protective, 
held  on  with  a  spica  bandage,  complete  the  dressing. 

In  case  the  intestinal  wall  is  broken  down,  or  is  so  nearly  necrotic 
that  its  return  into  the  cavity  of  the  al^domen  is  attended  with  danger 
of  rupture  of  the  gut  and  escape  of  its  contents,  two  alternatives  present 
themselves,  viz.:  to  leave  the  intestine  protruding,  and  establish  an  arti- 
ficial anus  ;  or  to  exsect  the  dead  portion  and  sew  the  ends  together.  If 
the  patient  is  in  good  condition,  and  especially  if  in  the  prime  of  life  and 
usefulness,  exsection  should  be  done.  If,  on  the  other  hand,  collapse  is 
imminent,  or  if  there  is  anything  in  the  condition  of  the  patient  to  contra- 
indicate  a  prolonged  operation,  the  fecal  fistula  should  be  established. 

Exsection  is  performed  as  follows  :  Release  the  strangulation  as  above 
described,  and  draw  out  both  ends  of  the  bowel  until  .six  or  eight  inches 
of  sound  gut  are  exposed.  Place  a  clamp  or  throw  a  loop  of  disinfected 
tape  around  each  end  of  the  intestine  near  the  ring,  to  prevent  the  i3o.ssi- 
bility  of  retraction  or  escape  of  the  bowel  or  its  contents  inward.  With 
sharp  scissors  divide  the  intestine  squarely  across  at  each  end  of  the 
limit  of  necrosis,  and  cut  a  triangular  piece  from  the  me.sentery,  the  base 
of  which  corresponds  exactly  to  the  section  of  intestine  removed.  Ligate 
all  l)Ieeding  points  in  the  mesentery.  The  operation  is  completed  in  the 
same  manner  as  in  exsection  of  the  intestine,  given  on  a  preceding  page. 

When  it  is  desired  to  establish  an  artificial  anus,  the  strangulation 
should  be  relieved  as  already  directed,  and  the  bowel  incised.  As  a 
rule,  it  is  not  necessary  to  stitch  the  gut  to  the  wound,  on  account  of 
the  adhesions  which  usually  exist. 

In  the  course  of  a  few  weeks,  after  the  patient  has  fully  recovered 
from  the  effects  of  the  strangulation  and  the  operation,  the  canal  may  be 
restored,  by  opening  the  abdomen,  exsecting  the  protruding  and  attached 
portion  of  intestine,  and  imiting  the  ends  by  stitches.  Or  the  operation 
of  Dupuytren  may  be  undertaken.  It  con.sists  in  gradually  breaking 
down  the  promontory  formed  by  the  contiguous  walls  of  the  incarcerated 
loop,  and,  when  this  is  done,  allowing  the  external  wound  to  close  by 


508 


A  TEXT-BOOK   ON   SURGERY. 


granulation,  'i'he  instrument  used  in  tliis  operation  is,  in  shai)e,  not 
unlike  a  pair  of  forceps,  with  Hat,  roughened  jaws,  and  long  handles, 
which  can  be  locked  witli  a  damp.     Tlie  jaws  are  introduced  at  first  for 


a  slight  distance  only,  one  going  into 


the  ascending  and 


tile  other  into 


Fio.  C47. — Dupuytrcn'.s  clamp.    (After  Gross.) 


the  descending  part  of  the  looi?  of  intestine,  when  they  are  closed  and 

clamped  in  such  a  manner  that  the 
walls  of  the  promontory  are  held  lirm- 
ly  in  contact  (Fig.  547).  The  instru- 
ment is  allowed  to  remain  in  ixhsition. 
Adhesion  occurs  in  the  contiguous  peri- 
toneal coverings  of  the  gut,  while  that 
part  of  the  promontorj'  firndy  grasjied 
by  the  instrument  is  crushed  or  slougiis 
away.  As  soon  as  the  projection  is 
sufficiently  broken  down  the  fistulous 
opening  may  be  allowed  to  close. 

This  procedure  has  been  successful 
in  a  number  of  cases  sufficient  to  jus- 
tify its  employment.  If  a  cure  is  not 
effected,  or  if  stricture  should  result, 
exsection  should  be  perfonned. 

Inguinal  hernia  in  the  female  has 
the  same  relation  to  the  epigastric  ves- 
sels as  in  the  male  subject.     In  the 
complete  form   the   contents  may  de- 
scend into  the  labium.     The  treatment 
does  not  differ  materially  from  that  just  given. 
Nuck  not  infrequently  simulate  a  hernial  tumor, 
descends  into  the  canal. 

Femoral  Hernia — Treatment. — This  form  of  hernia  is  more  difficult 
to  retain  in  place  with  a  truss,  and  is  more  likely  to  become  incarcerated 
and  strangulated,  than  any  other  variety.  The  j^i'ognosis  is,  therefore, 
more  unfavorable.  The  diar/nosis  depends  upon  the  presence  of  a  tumor 
in  the  location  already  given  (Fig.  540),  the  neck  of  which  can  be  traced 
to  an  opening  at  the  inner  side  of  the  thigh,  just  external  to  the  spine  of 
the  pubes,  and  below  Poupart's  ligament.  The  impulse  in  coughing  is 
present,  though  usually  less  perceptible  than  in  inguinal  hernia.  Cysts 
are  less  apt  to  complicate  a  femoral  than  an  inguinal  hernia.  Enlarge- 
ment of  the  lym])hatic  glands  will  not  be  apt  to  mislead,  since  there  will 
have  been  a  history  of  adenitis,  a  gradual  increase  in  the  size  of  the 
glands,  which  may  be  recognized  as  a  group.  The  absence  of  impulse 
with  the  act  of  coughing  will  further  aid  in  the  exclusion  of  hernia. 

The  symptoms  of  strangulation  differ  in  no  essential  features  from 
those  in  inguinal  hernia. 

Treatment. — A  reducible  femoral  hernia  should  be  retained  within 
the  abdomen  hy  a  truss,  the  pad  of  which  presses  finnly  over  the  femoral 
ring,  just  external  to  the  spine  of  the  pul)is.  The  pad  should  be  small, 
so  that  it  may  not  comi^ress  the  femoral  vein,  and  the  spring  should  be 


Cysts  of  the  canal  of 
Occasionally  the  ovary 


HERNIA.  509 

strong,  for  this  form  of  hernia  is  not  only  diflBcult  to  retain,  but  is  doubly 
dangerous  when  it  escapes  by  the  side  of  the  pad. 

In  reducing  femoral  hernia,  position  is  invaluable,  and  taxis  may  be 
of  aid.  The  best  position  without  taxis  is  the  knee-shoulder  posture,  in 
which  the  abdominal  muscles  and  fascia  lata  are  relaxed,  and  the  contents 
of  the  abdomen  gravitate  toward  the  diaphragm.  Or  the  dorsal  decubitus 
may  suffice,  with  the  pelvis  elevated,  as  well  as  the  foot  of  the  bed,  and 
the  thighs  flexed  upon  the  abdomen.  In  performing  taxis  it  must  be 
remembered  that  the  bulk  of  the  hernia  must  pass  directly  backward  to 
clear  the  falciform  process  of  the  fascia  lata,  and  then  upward  in  the 
direction  of  the  femoral  canal  (Fig.  540).  No  operation  for  the  radical 
cure  of  femoral  hernia  is  justifiable  unless  it  is  positively  demonstrated 
that  the  tumor  can  not  be  retained  by  any  prothetic  apparatus. 

If  an  operation  is  necessitated,  the  femoral  ring  should  be  exposed  by 
a  perpendicular  incision,  and  the  outlet  closed  by  stitching  the  cribilfonn 
fascia  and  the  falciform  process  to  the  edges  of  the  ring  with  strong  cat- 
gut sutures.  A  sublimate  gauze  compress  should  be  applied  after  the 
operation,  and  the  patient  kept  in  the  recumbent  posture  for  two  weeks. 
A  truss  should  be  worn  for  at  least  a  year  after  the  operation,  and,  when 
discarded,  should  be  resumed  at  the  first  indication  of  weakness  in  the 
canal. 

Irreducible  (not  strangulated)  femoral  hernia  may  be  treated  as  ad- 
vised for  the  same  form  of  inguinal  rupture.  Operative  interference  is, 
however,  more  justifiable,  from  the  fact  that  strangulation  is  more  apt  to 
occur,  and  that  a  compress  to  prevent  a  further  descent  of  the  mass  is 
rarely  successful. 

In  strangulated  femoral  hernia  operative  interference  is  indicated 
immediately  upon  the  first  symptoms  of  this  condition.  So  rapid  are 
the  changes  which  occur  in  the  contents  of  the  sac  that  early  operation, 
always  commendable  in  every  form  of  strangulated  hernia,  is  especially 
so  in  the  variety  under  consideration.  Taxis  should  not  be  performed 
until  the  patient  is  fully  anjesthetized.  The  preparation  for  the  opera- 
ti(m  is  identical  with  that  for  inguinal  hernia.  When  narcosis  is  com- 
plete, the  patient  should  be  lifted  by  the  legs  in  such  a  way  that  the 
thighs  will  be  flexed  upon  the  abdomen,  and  the  pelvis  raised  consider- 
ably higher  than  the  thorax.  "While  in  this  position  taxis,  in  a  direction 
at  first  slightly  backward  and  then  upwai'd,  should  be  practiced.  If 
reduction  is  not  effected  in  from  five  to  ten  minutes,  it  should  be  discon- 
tinued. 

The  incision  should  be  vertical  in  direction,  along  the  middle  of  the 
tumor,  with  its  center  over  the  femoral  ring.  The  length  will  vary  with 
the  size  of  the  protrusion,  but  three  or  four  inches  will  usiially  suffice. 
It  should  be  made  by  cutting  directly  down  upon  the  sac,  and,  when  this 
is  reached,  the  dissecticm  should  be  continued  between  two  dissecting- 
forceps.  When  the  sac  is  opened  and  tbe  fluid  escapes,  the  index-finger 
should  be  introduced  and  carried  upward  until  the  end  passes  beneath 
the  falciform  process,  and  the  nail  is  under  the  sharp  constricting  edge 
of  Gimbernat's  ligament.     At  this  stage  of  the  operation  the  hernia' must 

32* 


510  A  TEXT-BOOK   ON   SURGERY. 

be  kept  between  the  finger  and  the  femoral  vein,  and  the  edge  of  the  nail 
against  Gimbernat's  ligament,  just  at  its  insertion  at  tlie  os  pubis.  A 
long,  probe-pointed  knife  is  now  rarried  flatwise  along  tlit*  pabnar  side  of 
the  finger,  with  the  cutting  edge  directed  toward  the  median  line.  The 
constriction  is  relieved  by  lifting  or  scraping  the  attachment  of  Gimbei- 
nat's  ligament  from  the  os  pid)is,  and  in  doing  this  the  cutting  edge  of 
the  knife  should  not  be  carried  beyoud  tiiis  ligament,  nor  should  it  have 
any  other  direction  than  inward  toward  the  symphysis.  If  these  precau- 
tions are  not  observed,  a  dangerous  com])lication  may  arise  in  the  division 
of  the  obturator  artery  (or  vein),  in  cases  in  which  it  is  derived  from  the 
epigastric  branch  of  the  external  Uiac.  In  eight  fatal  cases  of  this  char- 
acter the  patients  were  females.  This  abnornud  derivation  occurs  in 
women  in  nearly  50  per  cent  of  cases,  and  in  25  per  cent  in  men,  while 
the  vein  is  in  relation  to  the  femoral  ring  in  a  larger  proportion  of  cases.  * 
The  manner  in  which  the  artery  arches  over  the  crural  ring  is  shown  in 
Fig.  .531).  "When  the  strangulation  is  released,  and  the  contents  of  the 
sac  returned  into  the  abdomen,  an  effort  should  be  made  to  effect  a  radi- 
cal cure  as  above  directed. 

Umbilical  Hernia. — The  diagnosis  between  this  form  of  hernia  and 
other  tumors  of  the  umbilical  region  will  depend  chiefly  upon  the  im- 
pulse conveyed  to  the  hernia  in  the  act  of  coughing,  or  in  crying  in 
children.  If  the  hernia  is  made  up  of  omentum — and  this  is  not  un- 
common in  adults — it  will  be  doughy  to  the  feel  and  flat  or  dull  on  jier- 
cussion.  Intestine  will  be  more  or  less  resonant  on  percussion.  If  the 
mass  is  reducible  in  the  recumbent  posture,  and  under  direct  manipula- 
tion the  diagnosis  of  hernia  is  evident.  Cyst  of  the  omphalo- mesenteric 
duct  would  be  translucent,  and  fluctuation  would  be  present.  In  con- 
genital hernia  the  extreme  thinness  of  the  covering  renders  the  recog- 
nition of  the  character  of  the  tumor  easy. 

Treatment. — When  an  umbilical  hernia  which  is  only  covered  by  the 
thin  membrane  of  the  cord  exists  at  birth,  it  should  be  returned  at  once, 
and  the  opening  closed  by  carefully  adjusted  sutures,  supported  by  ad- 
hesive strips,  drawn  in  dove-tail  fashion  across  the  abdomen  at  the  weak 
point.  If  covered  over  with  integument,  it  should  be  reduced,  a  small, 
firm  compress  placed  in  the  opening,  and  secured  in  place  by  a  band  of 
adhesive  plaster  carried  around  the  child's  bell.y.  The  acquired  form 
is  treated  in  the  same  general  way.  It  should  be  reduced  by  posture, 
aided  by  careful  taxis  if  necessary,  and  a  truss  worn  day  and  night.  In 
mild  cases  a  light  rubber  belt  wiU  suffice  after  retiring  for  the  night, 
but  the  heavier  apparatus  should  be  adjusted  before  leaving  the  recum- 
))ent  posture. 

Irreducible  hernia,  not  strangulated,  may  be  held  in  position  by  a 
I>roperly  adjusted  cup-shaped  compress. 

The  danger  of  strangulation  is  always  present,  and  the  question  of 
the  advisability  of  operating  to  relieve  the  incarceration,  and  of  sewing 

*  The  anthor's  "  Essays  in  Surgical  Anatomy  and  Surgery."     William  Wood  &  Co.,  1878. 
"  New'York  Medical  Record,"  October.  1877. 


IIERXIA.  511 

up  the  opening,  must  be  determined  by  the  circumstances  of  each  par- 
ticular case.  As  a  rule,  an  operation  is  not  indicated  unless  strangula- 
tion is  threatened,  and  this  is  especially  the  case  when  the  patient  is 
situated  within  the  easy  call  of  a  competent  operator.  Under  other  con- 
ditions operative  interference  may  be  seriously  considered. 

AVith  the  first  symptoms  of  straitgulation  the  patient  should  be 
etherized,  and  a  final  effort  at  reduction  made  by  careful  taxis.  If  this 
does  not  succeed,  kelotomy  should  be  at  once  pei'formed.  The  incision 
should  be  vertical,  with  its  center  corresponding  to  the  neck  of  the  her- 
nia. On  account  of  the  exceeding  thinness  of  the  integument  and  other 
coverings,  great  care  shoidd  be  exercised  in  cutting  down  upon  the 
tumor.  As  soon  as  the  sac  is  punctured,  the  dull  director  is  introduced, 
and  the  sac  divided  sufficiently  to  allow  the  introduction  of  the  finger, 
upon  which  the  further  division  of  the  sac  is  made.  If  the  finger-nail 
can  now  be  insinuated  between  the  neck  of  the  hernia  and  the  constrict- 
ing ring,  it  should  be  done,  holding  the  palmar  aspect  of  the  finger 
toward  the  pubes.  The  probe-i^ointed  bistoury  is  now  introduced  flat- 
wise, and  the  constriction  divided  for  not  more  than  a  quarter  of  an  inch 
at  first.  The  direction  of  this  cut  should  be  in  the  median  line,  and 
toward  the  pubes ;  or  the  constriction  may  be  incised  on  the  upper  aspect 
of  the  neck  if  mdre  convenient  to  the  operator. 

The  management  of  the  strangulated  bowel  or  omentum  should  be 
the  same  as  advised  in  inguinal  hernia.  The  sac  should  be  transhxed 
with  a  strong  double  catgut  ligature,  tied  each  way,  the  part  beyond  the 
ligatures  cut  off,  and  the  stump  returned  within  the  abdomen.  The 
radical  cure  should  be  attempted  by  introducing  a  fiat  Thiersch  sponge 
through  the  opening,  which  will  prevent  blood  or  other  matter  from  en- 
tering the  peritoneal  cavity.  The  margins  of  the. opening  should  now 
be  trimmed  so  as  to  secure  freshened  edges  for  approximation.  When 
all  bleeding  has  ceased,  the  sponge  should  be  removed.  The  parietal 
layer  of  peritonaeum  should  be  stitched  by  a  separate  row  of  catgut 
sutures,  and  the  fascia,  aponeuroses  of  the  muscles,  and  integument 
brought  together  by  silk  or  silver-wire  sutures.  If  for  any  reason  the 
separate  row  of  sutures  are  not  introduced,  the  outside  row  should  trans- 
fix the  peritoneal  layer  of  the  abdominal  wall  about  one  fourth  of  an 
Inch  from  the  margin  of  the  wound,  so  that,  when  the  sutures  are  tied, 
this  much  of  the  peritoneal  surface  of  the  two  sides  will  be  bi-ought 
into  apposition. 

Ventral  Tieniia  is  amenable  to  the  same  general  treatment  as  the 
acquired  umbilical  variety.  In  operation  for  the  cure  of  hernia  after 
laparotomy,  the  parietal  peritonaeum  should  be  first  closed  with  catgut. 
In  closing  the  remainder  of  the  wound  the  sutures  should  be  made  to 
include  both  layers  of  the  dense  sheath  of  the  rectus  muscle. 

In  diapJiragmatlc  hernia  tlie  diagnosis  must  be  based  upon  the  symp- 
toms of  obstruction.  Pleuritis  will  be  present  in  a  varying  degree.  The 
only  means  of  arriving  at  a  positive  diagnosis  is  to  make  the  median 
incision,  with  manual  exploration.  The  hernia  may  be  reduced  by  trac- 
tion, with  or  without  dilatation  of  the  opening  in  the  diaphragm.     The 


512  A  TEXT-BOOK  ON  SURGERY. 

prognosis  is  unfavorable,  and  the  gravity  is  increased  as  operative  inter- 
ference is  delayed. 

The  rt'coa-nition  of  rfhtfeal  Itrrnia  is  also  difficult.  If  with  the  symp- 
toms of  obstruction  there  is  i)ain  in  the  region  of  the  sciatic  notch,  or  in 
the  distribution  of  the  gluteal  or  sciatic  nerves,  which  is  increased  by 
direct  pressure,  the  presence  of  gluteal  hernia  is  usually  certain.  If  a 
tumor  is  appreciable,  it  is  still  more  positive. 

To  locate  the  notch,  place  the  patient  on  his  belly  and  hold  the  leg 
perfectly  straight,  with  the  toes  i^nnting  directly  downward.  A  line, 
drawn  from  the  posterior  superior  spine  of  the  ilium  to  the  upper  sur- 
face of  the  great  trochanter,  will  cross  over  the  foramen. 

The  incision  should  be  free,  and  the  iibers  of  the  gluteal  muscles 
separated  with  the  finger.  The  vessels  should  be  located  before  the  con- 
striction is  divided. 

Obturator  hernia  may  be  present  without  any  appreciable  tumor.  It 
may  be  recognized  by  digital  exploration  through  the  rectum  or  vagina. 
Pressure  upon  the  obturator  nei-ve  may  i)roduce  pain  in  the  hip  or  knee. 
If  the  symptoms  of  obstruction  are  present,  the  hand  should  be  intro- 
duced through  an  incision  in  the  linea  alba,  when,  by  careful  explora- 
tion of  the  i)elvis,  the  character  of  the  lesion  can  be  determined.  In 
the  effort  at  reduction  by  traction  from  within,  the  thigh  should  be  ro- 
tated outward  to  relax  the  obturator  muscle.  If  necessary,  an  incision 
may  be  made  immediately  over  the  foramen,  and  the  constriction  divided 
from  below.  The  point  at  which  the  intestine  usually  escapes  is  in  the 
adult  between  two  and  two  and  a  half  inches  external  to  the  symphysis 
pubis,  and  on  a  line  with  the  inner  border  of  the  femoral  or  iliac  vein. 
When  the  fibers  of  the  pectineus  muscle  are  divided,  the  tumor  will  be 
encoimtered. 

Lumbar  and  var/inal  hernia  do  not  demand  especial  consideration. 
Tlie  diagnosis  will  depend  upon  the  appearance  of  the  tumor,  with  the 
symptoms  of  strangulation,  when  the  constriction  is  sufficient.  The 
return  of  the  mass  which  follows  prolapsus  of  the  uterus  into  the  vagina 
may  be  effected  by  direct  rejiositicm  of  the  uterus,  or  by  conjoined 
manipulation  with  one  hand  introduced  through  an  opening  in  the  linea 
alba. 

Fecal  Fistula. — A  fecal  fistula  may  exist  between  any  portion  of  the 
intestinal  canal  and  the  external  muscle  through  the  integument ;  from 
the  intestine  into  a  normal  cavity,  as  the  bladder  or  uterus,  and  thence 
to  the  exterior ;  into  an  abnormal  cavity,  as  an  abscess,  and  thence 
out  through  one  of  the  hollow  organs  or  directly  to  the  skin ;  or  it  may 
lead  into  a  cul-de-sac  or  blind  pocket. 

Fecal  fisiulse  are  congenital  and  acquired. 

Imperforate  anus  is  the  most  frequent  cause  of  congenital  fistula. 
The  pressure  of  accumulated  matter  at  the  extremity  of  the  canal  in- 
duces iufiammation,  ulceration,  and  perforation,  with  extravasation  of 
the  bowel  contents.  If  the  congenital  obstruction  is  low  down,  the  open- 
ing may  occur  through  the  penmcum,  bladder,  or  vagina.  If  higher  up, 
the  fistula  may  open  through  the  abdominal  wall  at  the  umbilicus,  or 


FECAL  FISTULA.  513 

below  tliis  point  in  the  linea  alba,  or  posteriorly  near  the  spine.  A  rare 
cause  of  congenital  fistula  is  the  presence  of  the  omphalo-mesenteric 
duct,  or  Meckel's  diverticulum,  which,  as  heretofore  stated,  opens  at  the 
umbilicus. 

Acquired  fecal  fistulse  may  be  surgical  or  accidental.  Colostomy 
and  enterostomy  are  examples  of  the  foi-mer,  while  the  latter  result  from 
perforating  wounds  of  the  intestinal  canal,  either  from  the  exterior,  as 
by  gun-shot  or  punctured  wounds,  or  by  the  passage  of  some  ingested 
sharjj  or  hard  body  through  the  intestinal  wall ;  or  by  perforation  of  the 
intestine  by  an  ulcer  or  abscess,  or  from  gangrene  due  to  strangulation, 
contusions,  etc. 

The  diagnosis  of  a  fecal  fistula  which  communicates  directly  with 
the  exterior  is  made  evident  by  the  escape  of  gas  and  ingested  matter. 
Indirect  fistulse  can  also  be  determined  by  the  careful  examination  of 
the  discharges  from  the  organs  through  which  they  pass.  In  a  case  re- 
jjorted  by  Dr.  Krackowitzer,  in  the  "Transactions  of  the  Xew  York 
Pathological  Society,"  an  ulcer  of  the  appendix  vermiformis  had  opened 
into  the  bladder.  The  diagnosis  of  entero-vesical  fistula  was  established 
by  the  escape  of  a  lumbricoid  worm  from  the  urethra.  Blind  fistulfe  can 
not  often  be  made  out  until  demonstrated  by  exploration. 

In  determining  what  portion  of  the  intestinal  canal  the  fistula  opens 
into  one  must  consider,  first,  the  character  of  the  discharge  ;  second,  the 
distance  from  the  rectum,  as  determined  by  injections. 

In  congenital  fistulce  opening  into  the  perinaeum  the  inference  is 
natural  and  generalh^  correct  that  the  lower  portion  of  the  large  intestine 
is  involved.  If  bile  is  freely  discharged  through  a  congenital  or  ac- 
quired fistula,  it  is  safe  to  conclude  that  the  opening  is  not  very  far 
removed  from  the  duodenum  or  upper  ])ortion  of  the  jejunum.  The 
odor  of  gas  or  ingesta  escaping  from  the  large  intestine  is  usually  more 
offensive  than  that  from  the  small  bowel. 

When  caused  by  a  wound,  the  known  direction  and  character  of  the 
penetrating  body  will  aid  in  arriving  at  a  correct  idea  of  the  gut  pene- 
trated. 

A  fistula  resulting  from  perityphlitic  abscess  occurs  almost  always 
in  the  ccecum,  more  rarely  in  the  lower  portion  of  the  ascending  ct)lon 
or  lower  ileum.  When  the  colon  is  involved  the  location  may  be  deter- 
mined by  slowly  injecting  milk  per  rectum,  having  measured  the  quan- 
tity injected  until  it  begins  to  flow  out  at  the  external  opening. 

The  prognosis  of  fecal  fistula  depends  upon  its  character.  Congeni- 
tal fistulffi  are  obstinate  under  treatment.  Acquired  fistulse  maybe  cured 
in  the  majority  of  instances. 

Treatment. — Congenital  fistulse,  resulting  from  imperforate  anus,  can 
only  be  healed  by  the  establishment  of  an  opening  in  the  perinseum 
which  shall  communicate  with  the  most  dependent  portion  of  the  blind 
gut.  When  this  is  done,  a  pad  worn  over  the  fistulous  opening  will 
lead  to  its  gradual  occlusion.  When  the  fistula  is  the  result  of  a  patu- 
lous omphalo-mesenteric  canal,  it  may  be  closed  by  sutures  or  by  a  com- 
press. 

33 


514  A  TEXT-'BOOK  ON  SURGERY. 

Acquired  fistnlpc  not  infrequently  heal  spontaneously.  The  opera- 
tion consists  in  cuttinf;;  down  ui)()n  the  opening  in  the  gut  and  lay- 
ing freely  open  all  sinuses  wliicli  ('(ininiunicate  with  the  fistulous 
outlet.  As  the  track  of  the  fistula  is  ol'teii  tortuous,  it  is  at  times  ex- 
ceedingly difficult  to  follow  it.  A  repetition  of  the  method  employed 
in  the  following  case  will  be  of  service  in  the  more  complicated  oper- 
ations : 

In  1880  a  young  man  came  under  my  observation  on  account  of  a 
pistol-shot  wound.  The  bnll  had  entered  the  abdomen  on  a  level  with 
and  about  one  and  a  half  inch  to  the  inner  side  of  the  left  anterior  su- 
perior spine  of  the  ilium.  From  the  direction  in  which  the  weapon  was 
aimed,  the  missile  was  thought  to  have  passed  directly  back  and  lodged 
in  the  iliac  fossa.  There  were  no  immediate  symptoms  of  perforation 
of  the  intestine.  An  abscess  formed  which  discharged  from  the  wound 
of  entrance,  and,  about  six  weeks  after  the  receipt  of  the  injury,  a  fecal 
tistnla  was  established.  The  fistulous  track  was  so  long  and  tortuous 
that  it  could  not  be  followed.  After  the  an<esthesia  was  complete,  warm 
milk  was  thrown  into  the  bowel  until  it  ran  out  at  the  opening.  The 
stream  of  milk  was  then  followed  without  dilhculty,  and  the  opening 
discovered.  All  communicating  sinuses  were  laid  ojien  and  packed  with 
carbolized  gauze.  The  wound  closed  within  a  month,  and  the  patient 
was  cured. 

It  will  be  advisable,  in  attempting  to  close  the  fistula,  for  the  patient 
to  maintain  a  position  which  will  prevent  the  gravitation  of  ingested 
matter  into  the  opening. 

Closure  of  the  external  orifice  by  means  of  sutures  is  not  advisable, 
since  it  may  induce  fecal  infiltration.  A  recovery  is  usually  hastened 
when  the  margins  of  the  wound  in  the  integument  can  be  stitched  to  the 
edges  of  the  opening  into  the  bowel,  as  directed  in  enterostomy. 

Colostomy. — The  establishment  of  a  fecal  fistula  between  the  colon 
and  the  abdominal  wall  is  usually  performed  in  the  co^cum  or  first 
few  inches  of  the  ascending  portion,  the  lower  part  of  the  descend- 
ing colon,  or  in  the  sigmoid  flexure.  In  the  first  two  locations  the 
operation  is  retro-peritoneal ;  in  the  last  the  cavity  of  the  peritonaeum 
is  opened. 

Colostomy  is  indicated  as  a  palliative  measure  in  occlusion  of  the 
alimentary  canal  on  the  anal  side  of  the  operation  by  stricture,  neo- 
plasms, volvulus,  intussusception,  or  any  lesion  for  the  relief  of  which 
exsection  is  not  permissible.  In  chronic  colitis  or  proctitis,  it  is  a  cura- 
tive operation  in  giving  complete  rest  to  the  diseased  bowel  until  recov- 
ery ensues. 

In  selecting  the  place  of  operation,  the  right  or  left  lumbar  region 
should  be  chosen,  not  so  much  for  the  reason  that  the  gut  may  be  ex- 
posed in  a  part  uncovered  by  peritonfenm  (for  opening  into  this  cavity 
is  no  longer  the  dangerous  procedure  it  was  supposed  to  be),  but  because 
the  situation  of  the  opening  here  is  the  most  suitable  for  wearing  a  pro- 
tecting a])paratus,  and  secures  a  greater  degree  of  cleanliness  in  the 
after-manairement  of  the  fistida. 


COLOSTOMY.  515 

^Yhen  the  rectum  and  lower  portion  of  the  sigmoid  flexure  are  in- 
volved, the  left  lumbar  region  should  be  selected  :  if  the  descending  or 
transverse  colon  are  involved,  the  I'ight  lumbar  incision  is  preferable. 

CaUlsen''s  Operation — Left  Lumbar  Colostomy. — Place  the  patient  on 
the  right  side,  inclined  well  over  upon  the  abdomen.  The  objective  point 
is  the  posterior  surface  of  the  descending  colon,  at  a  point  situated  half- 
way between  the  crest  of  the  ilium  and  the  last  rib,  and  half-way  be- 
tween the  spinous  process  of  the  third  lumbar  vertebra  and  the  ante- 
rior superior  spine  of  the  ilium.  Make  an  incision  about  five  inches  in 
length,  the  center  of  which  shall  strike  this  point,  commencing  al»out 
one  inch  from  the  vertebral  spines.  The  dii'ection  of  this  incision  should 
be  oliliqiiely  from  above  downward  and  forward — that  is,  parallel  with 
the  lumbar  vessels  and  nerves.  Dividing  the  skin  and  fascia,  the  poste- 
rior border  of  the  abdominal  muscles  and  the  anterior  border  of  the 
quadratus  lumborum  muscle  will  be  seen.  The  posterior  wall  of  the 
colon — that  portion  which  is  not  included  in  the  peritonjeum — will  be 
found  a  little  posterior  to  the  border  of  this  muscle.  A  safe  guide  is  to 
insert  the  finger  along  the  edge  of  the  quadratus  muscle  and  feel  for  the 
kidney.  The  gut  is  immediately  in  front  of  this  organ.  It  is  important 
to  keep  well  toward  the  spine  in  order  to  avoid  opening  into  the  perito- 
nseum.  Usually  at  this  juncture,  with  the  wound  perfectly  dry,  the  wall 
of  the  intestine  can  be  picked  up  with  the  finger  and  lifted  toward  and 
into  the  wound.  If  it  has  receded,  deep  pressure  upon  the  anterior 
wall  of  the  abdomen  will  V)ring  it  into  view.  If  the  cavity  of  the  peri- 
tonaeum is  not  opened,  it  is  scarcely  possible  to  get  hold  of  the  small 
intestine.  The  colon  may  lie  recognized  by  its  large  size  and  by  its  sac- 
culated wall.  If  there  is  any  doubt  as  to  the  large  intestine  being  the 
one  which  presents,  the  expedient  of  pumping  air  into  the  rectum  may 
be  resorted  to,  the  immediate  distention  of  the  colon  proving  its  close 
relation  to  the  rectum.  As  soon  as  the  liowel  is  brought  into  the  wound, 
it  should  be  transfixed  by  two  strong  silk  sutures,  introduced  abf)ut  an 
inch  apart,  through  the  integument  of  one  side  into  the  intestine  for 
about  one  half  an  inch  and  out  again  and  up  through  the  margin  of  the 
incision  in  the  integument  on  the  opposite  side.  The  colon  is  now  held 
Avell  up  into  the  wound  by  traction  on  the  sutures  in  the  hands  of  an 
assistant,  while  the  operator  makes  a  longitudinal  incision  in  the  wall 
of  the  gut  supei-ficial  to  the  threads  which  have  transfixed  it.  AVhen 
this  is  done,  the  center  of  the  ligatures  is  drawn  out  by  a  tenaculum, 
divided,  and  the  four  threads  tied  securely.  From  two  to  four  addi- 
tional sutures  may  be  introduced  on  each  side,  to  guard  against  the 
infiltration  of  fecal  matter.  The  wound  in  the  integument  should  now 
be  closed  from  each  end  down  to  or  very  near  the  level  of  the  opening 
in  the  cokm. 

If  there  is  much  escape  of  fecal  matter  immediately  following  the 
operation,  a  dressing  need  not  be  applied.  The  patient  should  be  made 
to  lie  upon  the  back,  in  which  position  gravity  favors  the  escape  of 
the  bowel  contents.  At  times  it  is  convenient  to  apply  an  iodoform- 
ized  and  sublimate  gauze  dressing,  with  a  bandage  around  the  abdomen. 


516  A  TEXT-BOOK   ON  SURGERY. 

Ill  from  three  to  seven  days  the  stitches  can  be  removed,  and,  after  the 
wound  is  healed,  a  compress  and  belt  should  be  worn  to  prevent  the 
escape  of  fjeces  until  the  convenience  of  the  ])atient  is  suited. 

If  in  the  search  for  the  colon  the  cavity  of  the  periton;eum  is 
opened,  it  should  be  immediately  sewed  up  with  continuous  catgut 
sutures. 

If,  after  colostomy,  prolapse  of  the  intestine  occurs,  it  may  be  re- 
turned and  held  in  place  by  a  properly  adjusted  comj)ress  of  gauze.  If 
the  opening  contracts  to  such  an  extent  tliat  the  escai)e  of  fecal  matter 
is  hindered,  it  slunild  be  dilated  with  the  linger  or  by  means  of  a  gum 
or  sponge  tent. 

Amussat's  operation,  or  rirjlit  lumbar  colostomy,  is  performed  in  the 
same  manner  as  the  procedure  just  given,  ui)on  the  opposite  side  of  the 
body.  Little's  operation  is  performed  by  opening  into  the  i)eritoneal 
cavity  by  an  incision  in  the  abdominal  wall  just  internal  to  the  left  ante- 
rior spine  of  the  ilium  over  the  sigmoid  flexure.  The  small  intestines  are 
disx>laced  to  the  right,  while  the  sigmoid  Hexure  is  brought  u})  to  tlie 
wound  and  fastened  by  two  rows  of  sutures.  The  first,  of  line  silk, 
attach  the  edge  of  the  parietal  peritonaeum  to  the  peritoneal  layer  of 
the  gut,  while  those  of  the  second  row  jiass  through  the  integument 
and  into  the  lumen  of  the  intestine,  as  in  colostomj'.  A  like  operation 
may  be  done  upon  the  transverse  colon,  although  either  of  these  pro- 
cedures will  be  rarely  indicated. 

Peritonitis. — In  properly  selected  cases,  abdominal  section  for  the 
relief  of  peritonitis  with  effusion  has,  within  late  years,  become  a  recog- 
nized operation.  It  is  more  a})plicable  to  cases  of  local  peritonitis,  and 
in  chronic  inflammation  of  this  membrane,  than  in  acute  general  perito- 
nitis. The  operation  is  justitiable  in  the  acute  inflammation  which  fol- 
lows perforation  of  the  alimentary  canal,  in  which  closure  of  the  perfo- 
ration, and  a  thorough  cleansing  of  the  cavity  of  the  peritonaeum,  are 
essential.  Left  without  operation,  these  cases,  almost  without  exception, 
end  fatally.  Also  in  chronic  local  peritonitis,  due  to  any  cause  in  which 
the  symptoms  of  septic  absorption  are  prominent.  The  same  principle 
should  apply  in  these  cases  as  in  chronic  effusions  into  the  pleural  cavity.* 
Mr.  Treves,  in  his  excellent  monograph,  cites  a  series  of  cases :  one  in 
which  Mr.  Hancock  opened  the  abdomen  for  chronic  local  peritonitis. 
due  to  disease  of  the  vermiform  appendix  ;  Mr.  Tait,  in  several  cases  of 
chronic  peritonitis  ;  Dr.  Savage,  in  eight  cases  of  pelvic  peritonitis  treated 
by  laparotomy  ;  Dr.  Playfair,  in  one  case  of  chronic  pueijieral  perito- 
nitis— all  ending  in  recovery. f  When  the  incision  is  made,  any  effused 
liquid  or  pus  should  be  removed  by  means  of  soft  Thiersch  sponges  on 
holders,  and  the  cavity  of  the  peritonaeum  flooded  with  warm  Thiersch 
solution  or  l-to-20000  sublimate  solution,  or,  if  neither  of  these  can  be 
had,  with  clean  warm  water  at  a  temperature  of  about  100°  F.  As  so(m 
as  it  is  introduced  it  should  be  removed  with  the  sjjouges,  and  the  irri- 
gation repeated  until  it  comes  away  clear. 

*  "Intestinal  Obstruction."    Lea,  Sons  &  Co.,  Pliiladclphi.!,  1884.  t  Ibid. 


ABSCESS   OF  THE  ABDOMINAL   REGION.  517 

In  two  instances  I  have  seen  the  sublimate  solution  employed  in  this 
manner  in  disinfection  of  the  entire  peritoneal  cavity  with  success. 

In  severe  and  obstinate  cases,  drainage  should  be  established  in  the 
same  manner  as  descril)ed  in  the  after-treatment  of  certain  ovarian  tumors. 

In  the  diagnosis  of  peritonitis,  pain  is  in  the  majority  of  instances 
an  early  and  prominent  sj-mptom.  It  is  intense  in  character,  almost 
constant,  being  first  noticed  in  a  given  point  and  extending  later  with 
the  progress  of  the  inflammation  to  any  portion  of  the  abdominal  cavity. 
Tympanites  exists  in  a  varying  degree,  the  patient  generally  lying  upon 
the  back,  with  the  legs  drawn  up  and  the  thighs  flexed  upon  tlie  abdo- 
men. .  The  abdominal  muscles  are  usually  rigid,  taking  no  part  in  the 
respiratory  act.  Constipation  is  the  rule  in  a  lai'ge  majority  of  cases. 
Vomiting  is  not  so  common  a  feature,  though  often  occurring  in  perito- 
nitis. Difficulty  in  urinating,  or  compjlete  retention,  occurs  in  some 
cases,  especially  in  those  in  which  the  inflammatory  process  is  marked ' 
in  the  pelvic  region.  The  pulse  is  increased  in  frequency.  Peritonitis 
is  in  almost  aU  instances  secondary  to  a  lesion  of  one  or  more  of  the 
abdominal  viscera. 

Abscess  in  the  Abdominal  Region. — Abscess  may  occur  between  the 
parietal  layer  of  the  peritonjeum  and  the  muscular  walls  of  the  abdo- 
men, within  any  circumscribed  area  of  the  peritoneal  cavity,  in  the  loose 
tissues  behind  the  peritonaeum  (retro-peritoneal  abscess),  and  in  the  sub- 
stance or  %vithin  the  capsules  of  any  of  the  viscera. 

The  diagnosis  of  extra-peritoneal  abscess  wiU  in  part  depend  upon 
the  localized  pain  or  tenderness  under  pressure,  and  the  induration  and 
oedema  which  are  characteristic  of  acute  inflammation  with  pus-fonna- 
tion,  together  with  the  usual  exacerbations  of  temperature,  with  or  with- 
out rigors  or  a  chill.  Fluctuation  may  be  appreciable  in  extra-peritoneal 
abscess  in  patients  with  thin  abdominal  walls,  and,  if  situated  between 
the  muscles  or  in  the  subcutaneotis  tissues,  is  usually  diagnosticated 
without  difficulty.  The  employment  of  the  exploring-needle  and  aspi- 
rator is  always  invaluable  in  the  recognition  of  an  abscess.  The  imme- 
diate indication  in  treatment  is  to  cut  down  upon  the  tumor,  using  the 
needle  which  has  indicated  the  presence  of  pus  as  a  guide,  until  the  sac 
is  reached,  puncturing  this  sufficiently  to  admit  the  point  of  the  closed 
dressing-forceps,  and  enlarging  the  opening  by  separating  the  handles 
of  the  instrument.  The  principles  of  irrigation  and  free  drainage  apply 
here  as  to  other  recent  collections  of  pus. 

Intra-peritoneal  abscess  is  usually  single,  although  in  exceptional 
instances  there  may  be  two  or  more  different  centers  of  supjiuration. 
The  most  frequent  locations  are  the  iliac  regions  and  the  pelvis.  In- 
flammation of  the  copcum  and  vermiform  appendix,  and  the  peritonaeum 
immediately  about  these  organs  (tijpTilitis  and  2^€ritgp7ilifis),  is  a  not 
infrequent  cause  of  abscess.  All  of  the  lesions  considered  under  the 
head  of  intestinal  obstruction  may  induce  the  formation  of  pus  in  the 
cavity  of  the  peritonpeum.  Abscess  occasionally  forms  between  the 
upper  surface  of  the  liver  and  spleen  and  the  diaphragm  as  a  result  of 
tearing  loose  portions  of  the  suspensory  ligaments  of  these  organs. 


518  A  TEXT-BOOK  ON    SURGERY. 

D/'agnosln. — Intni-peritonenl  abscess  must  be  differentiated  fi'om  neo- 
plasms, cysts,  fecal  impaction,  with  ccecitis  or  colitis,  all  tumors  resulting 
from  ohstriiction,  liydrone))!ir<)sis,  aneurism,  lia'niatoni:!,  and  aliseess 
within  the  solid  viscera.  The  characteristic  features  of  ne()i)lasnis,  fecal 
impaction,  and  the  varioiis  lesicms  which  induce  intestinal  occlusion,  have 
just  been  considered.  Hydronephrosis  develo]is  slowly,  and  has  a  his- 
tory of  obstruction  of  the  ureter  or  urethra  which  can  not  be  mistaken, 
while  the  expansile  pulsation  and  brtdt  of  an  aneurism  render  it  easy 
of  recognition.  Abscess  develops  quickly,  and  follows  an  injury  or  oc- 
curs in  the  course  of  some  inflammatory  process.  If,  after  a  blow  in  the 
h}'i)Ochondriac  region,  or  a  severe  fall,  tenderness  is  develojied  along 
the  ujiper  surface  of  the  liver  or  spleen,  accfmipanied  by  the  well-known 
constitutional  symptoms  of  ])us-fonnati(m,  i)erihe])atic  or  peris])lenic  ab- 
scess may  be  susi)ecfed.  The  same  symptoms,  occurring  in  the  course 
of  typhlitis  or  perityphlitis,  point  to  suppuration  in  the  region  of  the 
copcum.  In  like  manner  ovaritis,  metritis,  salpingitis,  cystitis,  and  pelvic 
cellulitis  are  conditions  which  not  infrecpiently  induce  abscess  in  the 
pelvic  peritonjeum. 

Induration  and  fluctuation  are  scarcely  a]>preciable  in  the  earlier  stages 
of  abscess  between  the  liver  or  spleen  and  diaphragm  on  account  of  the 
resistance  offered  by  the  ribs.  Localized  pleuritis  and  pain  in  the  re- 
spiratory act  should  not  be  without  significance  when  considen^d  with 
other  symptoms.  In  perityphlitic  abscess  induration  is  felt  early  in  the 
inflammatory  process,  tenderness  is  well  marked,  while  muscular  rigidity, 
especially  of  the  right  side  of  the  abdomen,  is  present.  There  are  dull- 
ness on  percussion  and  cedema  of  the  skin.  As  the  inflammatory  process 
extends,  the  induration  becomes  more  superficial  or  descends  along  the 
iliac  fossa.  Fluctuation  is  deep-seated  and  difficult  of  recognition  until 
there  is  either  pus  in  large  quantity,  or  the  wall  of  the  abscess  has  risen 
in  close  proxinuty  to  the  integument.  In  abscess  within  the  pelvis,  ex- 
ploration by  the  rectum  or  vagina  will  aid  in  a  correct  diagnosis. 

Treatment. — In  perihepatic  abscess  the  pus  should  be  evacuated  by 
means  of  the  as^jirator.  The  needle  should  be  of  sufficient  caliber  to 
allow  the  pus  to  come  away  freely,  and  should  be  introduced  in  the 
same  opening  and  to  the  same  depth  of  the  smaller  needle  which  was 
emploj-ed  in  arriving  at  a  diagnosis.  Washing  out  the  cavity  of  the 
abscess,  when  it  is  of  recent  formation,  is  not  advisable  for  fear  of  over- 
distention  and  rupture  of  the  sac.  Incision  and  free  drainage  may  be 
employed  when  the  abscess  is  large,  the  pus  superficial,  and  when  ad- 
hesions have  occurred  which  will  prevent  infiltration  into  the  general 
cavity  of  the  abdomen  or  pleura. 

Perityphlitic  abscess  demands  operative  interference  as  soon  as  the 
symptoms  point  to  a  collection  of  pus. 

If  the  presence  of  this  fluid  can  be  demonstrated  l>y  the  em])loyment 
of  the  smaller  aspirator-needle,  tht^  pi'ocedure  is  much  simplified.  In- 
stances will,  however,  occur  in  which  the  needle  fails  to  find  the  cavity 
of  the  abscess,  and  in  which  the  characteristic  sym})toms  of  this  lesion 
are  present,  and  in  these  cases  it  is  equally  imjjortant  to  operate.     The 


ABSCESS   OF  THE   ABDOMINAL  REGION.  519 

incision  should  be  free,  with  its  center  over  that  part  of  the  swelling  in 
which  the  pus  seems  nearest  the  surface.  If  the  exploring-needle  has 
been  succes-sfiilly  tried,  it  .should  be  left  in  position  as  a  guide  to  the 
pus.  The  dissection  should  be  made  with  great  care,  to  avoid  opening 
into  the  peritoneal  cavity,  either  directly  or  through  the  wall  of  tlie  al)- 
scess.  After  a  small  puncture  is  made  in  the  sac,  the  dressing-forceps 
should  be  employed  to  dilate  the  opening.  Irrigation  with  1-to-lOOOO 
sublimate  solution  should  be  made,  and  a  drainage-tube  inserted.  In  a 
certain  proportion  of  cases  fecal  fistula  will  occur  in  the  course  of  peri- 
typhlitic  abscess.     It  should  be  treated  as  heretofore  directed. 

As  to  the  propriety  of  operative  interference  when,  in  the  course  of 
perityphlitis,  perforation  of  the  appendix  or  rupture  of  an  abscess  into 
the  cavity  of  the  peritonseum  takes  place,  there  exists  a  diversity  of 
opinion.  The  hopelessness  of  the  case,  when  left  alone,  would  seem  to 
justify  an  effort  at  cleansing  the  peritoneal  cavity  and  closing  the  per- 
foration or  establishing  drainage  to  the  outside. 

Retroperitoneal  Abscess. — Abscess  behind  the  peritonaeum  is  usually 
circumscribed,  although  it  may  be  diffuse.  Commencing  at  any  portion 
of  the  posterior  abdominal  wall,  pus  is  apt  to  dissect  up  the  loose  tissues 
behind  the  peritongeum,  and  to  travel  downward,  pointing  ultimately  in 
one  of  the  following  situations:  Above  Poupart's  ligament,  external  to 
its  center ;  beneath  this  ligament,  in  Scarpa's  space  ;  over  the  iliac 
crest ;  in  the  gluteal  or  lumbar  region ;  at  the  obturator  foramen,  or 
less  frequently  it  may  empty  into  the  colon,  rectum,  bladder,  uterus, 
vagina,  or  pass  out  through  the  perina>um.  Occasionally  the  dissec- 
tion is  upward  into  the  pleura,  or  it  may  pass  across  the  spine  to  the 
opposite  side. 

Causes. — Ostitis  of  the  vertebrae,  ribs,  or  bones  of  the  pelvis,  rupture 
of  the  psoas  or  iliacus  muscles ;  lesions  of  the  kidneys  or  supra-renal 
capsules  (cysts,  neoplasms,  calculi,  pyelitis,  rupture  with  the  extravasa- 
tion of  blood  and  urine) ;  diseases  of  the  pancreas,  liver,  spleen,  duo- 
denum, colon,  and  rectum  ;  the  pelvic  viscera,  or  tubercular  changes  in 
the  lymphatics  of  this  region — may  cause  retroperitoneal  abscess. 

Diagnosis. — The  physical  signs  of  the  earlier  stages  of  pus-forma- 
tion behind  the  peritonaium  are  not  well  marked.  With  the  muscles 
fully  relaxed,  deep  pressure  upon  the  abdomen  from  before  backward 
may  demonstrate  the  presence  of  the  swelling.  Rigidity  of  the  muscles 
of  the  affected  side  is  apt  to  be  present,  and  in  walking  there  is  usually 
a  perceptible  limp.  AVhen  the  inflammatory  process  is  situated  in  the 
region  of  the  iliacus  and  psoas  muscles,  flexion  of  the  thigh  on  the  ab- 
domen, however  slight,  is  apt  to  occur.  The  constitutiimal  symptoms 
of  acute  abscess  will  be  the  chief  reliance  in  arriving  at  a  correct  diag- 
nosis. Tlie  history  of  an  injury,  or  the  i)resence  of  a  lesion  of  any 
of  the  organs  situated  in  this  region,  will  suggest  the  probability  of 
abscess. 

Extravasaticm  of  blood  (hfpmatoma),  as  far  as  the  swelling  is  con- 
cerned, may  simulate  abscess,  and  in  one  particular  may  mislead,  since 
the  blood  dissects  up  the  loose  tissues,  and  the  tumor  may  present  at 


520  A  TEXT-BOOK  ON  SURGERY. 

any  of  the  locations  named  for  the  pointing  of  the  abscess.  The  snd- 
denness  of  the  tumefaction  in  hfpniorrhage,  the  history  of  an  injury  (or  it 
may  be  aneurism),  and  the  absence  of  sei)ti('  fever,  are  sufficient  to  ex- 
clude abscess.  Lesions  of  the  kidneys  may  be  recognized  by  a  careful 
study  of  the  urine.  In  hydronephrosis  the  swelling  will  occur  without 
marked  pain  or  fever,  comes  on  gradually,  while  a  history  of  obstruc- 
tion will  be  given.  Tenderness  along  the  spines  of  the  vertebrte  sug- 
gests abscess.  Lastly,  the  aspirator-needle  introduced  from  behind  will 
determine  the  character  of  the  swelling. 

Trcatnwut. — Incision  and  free  drainage  should  be  the  rule  of  prac- 
tice in  acute  retroperitoneal  abscess.  When  the  pus  is  deep-seated,  opera- 
tion should  be  delayed,  provided  that  the  symptoms  of  septic  absorption 
are  not  too  urgent.  The  patient  should  be  kept  quiet  and  in  bed,  and  in 
the  dorsal  decubitus.  The  operation  and  after-treatment  are  practically 
the  same  as  in  extra-peritoneal  abscess. 


The  Liver. 

Hepatic  Abscess. — A  circiim scribed  collection  of  pus  within  the  sub- 
stance of  the  liver  is  comparatively  rare.  Usually  single,  there  may  be 
two  or  more  separate  abscesses,  which  vary  in  size  from  a  few  lines  in 
diameter  to  enormous  cavities  holding  a  gallon  or  more  of  pus.  They 
may  be  deep  or  superficial,  and,  while  no  porti(m  of  the  liver-substance 
is  exempt,  the  most  frequent  location  is  in  the  deeper  portions  of  the 
right  lobe. 

Causes. — Contusions,  lacerations,  penetrating  wounds,  and  the  lodg- 
ment of  foreign  bodies  are  among  the  traumatic  cairses  of  suppurative 
inflammation  of  the  liver.  Laceration  of  the  capsule  along  the  attached 
portion  of  the  suspensory  and  coronary  ligaments  not  only  leads  to  peri- 
hepatic abscess,  but  may  induce  suj^puration  in  the  deeper  portions 
of  this  organ.  Foreign  bodies  causing  hepatic  abscess  not  only  enter 
through  the  integument,  but  ingested  substances,  as  bones,  needles,  etc., 
have  been  known  to  pass  from  the  alimentary  canal  into  the  liver,  pro- 
ducing circumscribed  inflammation  and  suppuration.  Abscess  of  the 
liver  may  also  occur  secondary  to  an  inflammatory  process  in  any  of  the 
abdominal  organs  the  blood  from  which  is  returned  by  the  jiortal  vein. 
Lastly,  it  may  occur  in  the  course  of  acute  hepatitis,  where  neither  in- 
jury or  metastasis  has  occurred.  As  this  disease  is  almost  altogether 
confined  to  tropical  climates,  it  will  be  understood  why  hepatic  abscess 
is  so  much  more  frequent  there  than  in  the  colder  zones. 

Symptoms  and  Diagnosis. — The  early  recognition  of  hepatic  abscess 
is  exceedingly  difficult,  especially  when  the  deeper  portions  of  the  organ 
are  involved.  Pain  is  not  a  ju'ominent  symptom,  unless  there  exists  a 
perihepatitis,  in  which  case  it  is  exaggerated.  There  is  a  sense  of  heavi- 
ness or  fullness  about  the  liver,  exacerbations  of  temperature  occur, 
with  general  impairment  of  health.  Jaundice  is  not  present  unless  the 
bile-duct  is  compressed  by  the  tumor.      Cancer  of  the  liver  develops 


ABSCESS   OF  THE  LIVER.  521 

slowly,  has  a  history  of  progressive  emaciation,  occurs  usually  after  forty 
years  of  age,  and  is  nodular  to  the  feel. 

Empyema  may  be  mistaken  for  abscess  of  the  liver,  especially  when 
the  accumulation  is  considerable  and  the  liver  is  displaced  downward. 
It  may  be  recognized  by  the  interference  with  the  expansion  of  the  lung 
of  the  affected  side,  and  by  the  change  in  the  percussion-sounds  with 
the  change  in  position  of  the  thorax,  in  which  the  fluid  of  empyema  is 
displaced. 

Over-distended  gall-bladder  may  be  mistaken  for  abscess;  but  this 
error  may  be  eliminated  by  bearing  in  mind  its  location  in  front  and 
low  down,  where  abscess  is  exceedingly  rare,  and  also  by  ol)serving 
that  a  distended  gall-bladder  is  appreciably  movable  independently  of 
the  liver. 

Hydatid  cyst  of  the  liver  is  not  painful,  and  is  not  accompanied  with 
exacerbations  of  temperature,  with  the  exception  of  the  very  rare  occur- 
rence of  inflammation  of  the  cyst,  when  a  differentiation  is  practically 
impossible  without  aspiration  and  the  examination  of  the  fluid. 

When  the  accumulation  of  pus  is  considerable,  the  tumefaction  may 
be  recognized  by  palijation  and  the  diagnosis  made  positive  by  the  ex- 
ploring-needle. 

Tlie  'progjiosis  is  unfavorable.  Left  alone,  a  fatal  termination  occurs 
in  almost  all  cases — by  rupture  into  the  peritongeum  in  about  30  j^er  cent, 
into  the  lung  in  25  per  cent,  while  in  a  smaller  proportion  of  cases  the 
abscess  opens  through  the  integument. 

Treatment. — Evacuation  is  the  only  rational  treatment.  In  the  choice 
of  methods  the  character  of  the  abscess  will  determine  the  employment 
of  the  aspirator  or  drainage  by  incision. 

Aspiration  is  advisable  when  the  abscess  is  deeply  located,  and 
especially  so  when  strong  inflammatory  adhesions  have  not  been  formed 
between  the  wall  of  the  abscess  and  the  abdominal  or  thoracic  parietes. 
In  performing  this  operation  the  following  plan  shoiild  be  adopted : 

The  most  siiperficial  point  of  the  abscess  should  be  located  by  care- 
ful exploration  with  the  smallest  aspirator-needle,  and  the  thickness  of 
the  intervening  tissue  measured.  In  using  the  evacuator  it  is  necessary 
to  have  a  good-sized  needle  to  prevent  solid  particles  or  shreds  of  tissue 
from  the  abscess- wall  from  occluding  it ;  but  it  is  always  safer,  if  firm 
adhesions  have  not  occurred,  to  employ  the  smaller  points,  since,  after 
the  needle  is  withdrawn,  pus  is  not  so  ajit  to  escape  and  find  its  way  into 
the  pleural  or  peritoneal  cavities. 

The  needle  should  be  introduced  in  the  same  opening  and  to  the 
same  de^jth  as  the  exploring-needle,  and  the  x^us  slowly  withdrawn.  It 
is  considered  a  safer  plan  not  to  completely  empty  the  cavity  at  the  first 
operation.  The  procedure  should  be  repeated  on  the  second  or  third 
daj".  A  piece  of  sublimate  gauze  should  be  laid  over  the  puncture  and 
held  in  position  by  a  roller.  When,  after  repeated  use  of  the  aspirator, 
a  cure  is  not  effected,  and  when  the  tissues  between  the  most  superficial 
portion  of  the  abscess  and  the  integument  have  been  so  solidified  by 
adhesions  that*  infiltration  of  pus  can  not  occur,  the  abscess  should  be 


522         .  A  TEXT-BOOK   ON  SURGERY. 

opened  by  direct  incision,  its  contents  allowed  to  escape,  the  sac  thor- 
oughly irrigated  with  l-to-5000  sublimate,  and  a  drainage-tube  inserted. 
If,  after  cutting  dowoi  to  the  wall  of  the  abscess,  it  is  discoveied  that 
adlu'sions  have  not  occurred,  the  sac  sliould  not  be  opened.  The  wound 
should  be  packed  with  sublimate  gauze,  and,  in  four  or  live  days  after 
adhesions  have  l)een  established,  it  may  be  incised. 

Hydddd  Tu inuix. — Cystic  tumors  cau.sed  by  the  presence  of  the  echi- 
nococcus  honiinis,  the  huva  of  the  taenia  echinococcus  or  tape-worm, 
occur  in  the  liver  more  frequently  than  in  all  other  poi-tions  of  the  body 
They  vary  in  size,  may  be  multiple  or  single,  and  may  be  lodged  in 
any  portion  of  the  organ.  The  capsule  or  periphery  of  the  cyst  is  tirni 
and  dense,  and  may  undergo  calcification.  Developing  in  the  liver, 
hydatid  cysts  may  perforate  the  diaphragm,  rupture,  and  pour  their 
contents  into  the  pleura  or  lung  ;  or  they  may  extend  into  tlie  abdomi- 
nal cavity  as  far  down  as  the  pelvis.  In  rare  instances  they  open  into 
the  stomach,  vena  cava,  duodenum,  or  colon. 

The  diagnosis  of  hydatids  of  the  liver  may  be  made  from  abscess  by 
recognizing  an  elastic  fluctuating  tumor,  which  is  free  from  tenderness  or 
any  of  the  symptoms  of  inflammation  or  septicjeraia  which  are  always 
present  in  abscess ;  from  cancer  of  the  liver  by  its  fluctuation,  cancer 
being  solid,  hard,  and  nodulated.  The  cachexia  of  cancer  does  not  occur 
in  hydatids. 

In  distention  of  the  gall  bladder  jaundice  is  apt  to  exist,  while  it  is 
an  exceptional  complication  of  hydatid  cysts.  Aspiration  with  a  deli- 
cate needle  will  be  necessary  to  positive  diagnosis.  Hydatid  cysts  c(m- 
tain  a  watery  liquid,  nearly  clear  or  of  a  light  straw-color.  In  some  in- 
stances fragments  of  the  booklets  and  other  contents  of  the  cysts  may  be 
discovered. 

Treatment. — The  contents  should  be  drawn  off  with  the  aspirator, 
and  the  operation  repeated  if  necessary.  A  single  evacuation  not  infre- 
quently effects  a  cure. 

The  needle  should  be  introduced  into  the  most  superficial  portion  of 
the  tumor.  As  the  cyst  is  being  emptied,  the  abdominal  wall  imme- 
diately around  the  needle  should  be  pressed  toward  the  tumor,  and, 
when  the  operation  is  finished,  this  should  be  continued  by  a  compress 
of  sublimate  gauze,  held  snugly  in  place  by  a  bandage.  The  object  of 
this  is  to  prevent  infiltration  of  the  fluid  into  the  peritoneal  cavity.  In 
performing  this  operation  an  anaesthetic  should  not  be  administered,  on 
account  of  the  danger  of  rapture  of  the  cyst  from  vomiting.  Cocaine 
may  be  employed  locally.  Complete  rest  in  the  recumbent  posture 
should  be  enforced  for  at  least  a  week  after  the  aspiration.  If  at  any 
time  suppuration  is  precipitated,  direct  incision  and  free  drainage  are 
imperative.  If  repeated  aspirations  fail  to  effect  a  cure,  adhesions  being 
foiTOed  as  a  result  of  the  frequent  introduction  of  the  needle,  an  incision 
may  be  made,  or  the  operation  of  Verneuil  jjerformed.  This  consists  in 
the  introduction  of  a  large  trocar  and  canula,  evacuating  the  contents, 
and  inserting  for  prolonged  drainage  a  large  rubber  tube  through  the 
canula,  which  is  then  withdi'awn,  leaving  the  tube  in  position. 


THE  SPLEEN.  523 


The  Spleek. 

Abscess  — Abscess  of  this  organ  is  much  less  frequent  than  in  the 
liver.  It  may  exist  in  the  substance  of  the  spleen  or  in  the  perisplenic 
tissues. 

Abscess  of  the  spleen  may  be  caused  by  violence,  as  from  a  pene- 
trating wound,  a  contusion  with  laceration,  or  a  more  or  less  extensive 
rupture  of  the  capsule  and  spleen-substance  near  the  attachment  of  the 
suspensory  ligament. 

IdiopatJtic  abscess  of  this  organ  may  be  caused  by  embolism,  or  fol- 
low in  the  course  of  any  disease  which  interferes  with  its  nutrition. 

The  pi'ognosis  of  splenic  abscess  is  unfavorable.  If  left  without  sur- 
gical interference,  the  contents  may  escape  into  the  alimentary  canal  (as 
the  colon  oi-  stomach) ;  into  the  pleural  cavity  and  lung ;  or,  in  excep- 
tional instances,  open  through  the  integument.  Occasionally  abscess  of 
the  spleen  reaches  a  certain  size,  remains  passive,  and  becomes  a  chronic 
or  cold  abscess. 

Hijmptoms  and  Diagnosis. — Traumatic  abscess  may  be  suspected 
when,  after  an  injury,  persistent  tenderness  is  felt  in  the  region  of  this 
organ,  and  when  to  this  symptom  is  added  the  constitutional  disturbance 
which  is  a  part  of  the  history  of  acute  abscess.  In  general,  the  tender- 
ness is  more  marked  in  perisplenic  abscess  than  in  that  which  is  deep- 
seated.  Swelling,  with  induration,  possil)ly  fluctuation  and  oedema  when 
the  abscess  is  near  the  surface,  are  confirmatory  symptoms  of  suppura- 
tion, which  may  be  substantiated  by  the  exploring-needle  and  aspirator. 

In  idiopathic  abscess  the  symptoms  of  suppuration  may  be  masked 
by  the  febrile  movement  in  the  disease  in  the  course  of  which  it  occurs. 
The  treatment  is  the  same  as  for  hepatic  abscess. 

Cysts. — The  diagnosis  and  treatment  of  cysts  of  the  spleen  do  not 
difl'er  in  any  essential  features  from  similar  lesions  in  the  liver. 

Hernia  of  this  organ  may  occur  through  a  wound  in  the  abdomen, 
or  through  an  opening  resulting  from  extensive  sloughing.  If  the  hernia 
is  recent,  and  the  ])rolapsed  portion  is  not  strangulated,  it  should  be 
thoroughly  cleansed  in  l-to-5(»00  sul>liniate  solution  and  returned  into  its 
noi-mal  position.  The  structure  of  the  spleen  is  so  delicate  that  it  breaks 
down  readily  if  undue  force  is  employed.  If  the  organ  is  lacerated,  it 
will  be  advisable  to  throw  an  elastic  ligature  around  it  at  the  level  of  the 
skin,  apply  an  antiseptic  dressing,  and  allow  the  mass  to  be  removed  by 
sloughing  or  by  tlie  scissors,  as  soon  as  adhesions  have  occuired  at  the 
opening.  When  strangulation  has  taken  place,  the  ligature  will  not  be 
required. 

Complete  splcnrrfom//  may  be  demanded  in  displacement  of  this 
organ,  followed  by  interference  with  the  function  of  other  viscera,  or  for 
the  relief  of  pain  caused  by  the  spleen  in  an  abnormal  position.  It  has 
been  performed  in  several  instances  on  account  of  the  enlargement  of 
this  organ  in  leucocyth.-emia,  but  without  the  success  which  would  en- 
courage a  repetition  of  the  oj^eration. 


524  A  TEXT-BOOK  ON  SURGERY. 

In  the  extirpation  of  a  wandering  spleen,  the  incision  slionld  be  by- 
preference  in  the  linea  alba,  when  the  tumor  is  near  enough  to  be  reached 
through  an  opening  here.  All  adhesions  should  be  divided  between 
double  catgut  ligatures.  The  splenic  vessels  should  be  tied  witli  a  double 
ligature  of  strong  silk,  and  divided  between  the  knots. 

Pancreas. — Cystic  tumors  of  large  size  are  occasionally  met  with  in 
this  organ,  and  have  been  successfully  i-emoved  by  incision  in  tlie  median 
line,  the  operation  being  practically  the  same  as  in  ovariotomy. 


Wounds  of  the  Abdomen. 

Injuries  of  the  abdomen  are  divided  into  penetrating  and  non-pene- 
trating^ and  both  of  these  varieties  are  again  divisible  into  those  which 
involve  the  viscera  and  those  in  which  the  organs  escape. 

Non-penetrating  Wounds  of  the  Abdominal  Walls. — Confusions  may 
involve  the  integument,  produce  extravasation  in  the  subcutaneous  tis- 
sues, rupture  of  the  muscles,  or  displacement  or  rupture  of  a  viscus  and 
death  without  any  external  evidence  of  injury. 

Simple  contused  woimds  of  this  region  demand  no  especial  considera- 
tion. If  abscess  occurs,  the  same  rule  of  treatment  which  applies  to 
abscess  elsewhere  is  applicable  here.  Rupture  of  one  or  more  of  the 
muscles  may  occur  as  the  result  of  a  blow  on  a  muscle  in  tensif)n,  or 
by  muscular  action  alone.  The  rectus  abdominalis  is  most  frequently 
torn.  Hernia  is  ajit  to  follow  this  injury.  The  treatment  consists  in 
pei'fect  rest  and  well-adjusted  presstire  to  hold  the  viscera  within  the 
cavity  of  the  abdomen  until  cicatrization  can  take  place.  A  support- 
er should  be  worn  for  some  months  after  recovery,  or  permanently  if 
necessary. 

Displacement  or  rupture  of  an  organ  (as  the  kidney,  spleen,  etc.)  may 
be  caused  by  direct  violence  or  by  a  severe  fall.  The  diagnosis  will,  in 
the  first  lesion,  depend  upon  the  absence  of  the  organ  from  its  normal 
place,  and  the  recognition  of  the  tumor  in  the  new  position.  Laceration 
is  followed  by  haemorrhage,  at  times  profuse,  which  is  evident  from 
great  pallor  and  a  rapid  and  weak  pulse.  If  the  intestine  is  involved, 
the  escape  of  gas  or  fseces  is  followed  usually  by  profound  shock,  tym- 
panites, and  peritonitis.  Emphysematous  crackling  may  be  recognized 
on  palpation. 

The  first  indication  in  treatment  of  a  displaced  viscus  is  to  place  the 
patient  in  such  a  posture  that  gravity  will  aid  in  the  restoration  of  the 
organ  to  its  normal  position.  A  compress  and  bandage  may  be  usefiil 
in  some  instances.  In  rapture  of  a  solid  organ,  profound  quiet  should 
be  maintained.  AVhen  haemorrhage  is  alarming,  deligation  of  the  ex- 
tremities is  advisable.  Fluid  extract  of  ergot  hypodennically  may  be 
added.  If  the  symjitoms  of  rupture  of  the  alimentary  canal  are  pres- 
ent, the  abdomen  should  be  opened  in  the  median  line,  the  rupture 
closed,  or  an  artificial  anus  established,  and  the  peritoneal  cavity  care- 
fully washed  out. 


WOUNDS  OF  THE  ABDOMEN.  525 

Non-penetrating  incised,  punctured,  or  sJiot  wounds  of  this  region  do 
not  demand  especial  consideration.  The  former  should  be  closed,  while 
it  is  usually  safer  to  treat  the  jjunctured  and  shot  wounds  by  placing  a 
sublimate  compress  over  the  opening. 

Penetrating  Wounds.  — Wounds  of  the  abdomen  which  penetrate 
■without  wounding  any  internal  organ  should  be  closed  in  the  same  man- 
ner as  directed  for  the  closure  of  surgical  wounds  through  the  belly.  If 
an  internal  organ  is  involved,  the  abdomen  should  be  opened,  the  charac- 
ter of  the  lesion  ascertained,  and  proper  surgical  treatment,  instituted. 
Among  the  symptoms  wliich  aid  in  arriving  at  a  diagnosis  are  the  follow- 
ing :  If  the  injury  is  followed  by  the  vomiting  of  blood,  it  is  fair  to  con- 
clude that  the  stomach  or  duodenum  is  involved  ;  if  blood  is  passed  by 
the  rectum,  that  the  wound  is  farther  along  the  bowel ;  or,  if  hamiatiiria 
exists,  that  the  kidney,  ureter,  or  bladder  is  injured.  If  the  odor  of 
intestinal  gas  or  fjeces  is  present,  the  inference  is  clear  that  the  aliment- 
ary canal  is  opened.  BUe,  gastric  juice,  or  recently  ingested  matter  seen 
in  the  wound  or  recognized  by  the  sense  of  smell,  indicates  the  character 
of  the  injury  and  the  location  of  the  perforation.  The  crackling  sound 
peculiar  to  emphysema,  elicited  by  palpation,  indicates  the  presence  of 
intestinal  gas  in  the  loose  tissues,  beneath  the  peritonseum  (Dennis). 
Tympanitic  resonance  over  the  liver,  which  has  appeared  suddenly  and 
which  is  persistent,  is  a  diagnostic  sign  of  perforation  of  considei'uble 
value.  Shock  is  usually  severe,  although  in  some  cases  it  may  be  slight 
and  of  short  duration. 

In  shot-wounds  the  location  of  the  wound  of  entrance  (and  exit,  if  it 
exists),  together  with  the  known  direction  of  the  missile  and  the  force 
with  which  it  was  propelled,  will  be  of  aid  in  determining  the  character 
of  the  lesion  within.  A  bullet  passing  directly  or  obliquely  into  the 
abdomen,  at  or  below  the  level  of  the  umbilicus  (Fig.  53U),  can  scarcely 
miss  the  intestinal  tube,  and  wll  be  more  apt  to  make  a  number  of  holes 
than  a  single  wound.  Above  this  point  tlie  chances  of  escape  are  more 
favorable,  yet  so  fortunate  a  result  is  exceptional.  The  direction  and 
depth  of  a  stab-wound  may  also  be  determined  by  the  appearance  of  the 
wound  and  an  examination  of  the  instrument  with  which  it  was  intiicted. 
The  persistence  of  pain  in  a  given  point  within  the  abdomen  is  a  recog- 
nized symptom  of  a  penetrating  wound. 

Many  of  the  foregoing  symptoms  may  not  be  present  within  the  first 
few  hours  after  the  receipt  of  a  wound  which  has  penetrated  the  aliment- 
ary canal,  and,  beyond  the  external  wound  and  a  varying  degree  of  shock, 
there  may  be  no  symptom  of  perforation.  Temporary  contraction  of  the 
muscular  fibers  of  the  stomach  or  intestine,  or  prolapse  of  the  raucous 
membrane  into  the  wound,  may  jirevent,  for  a  time,  the  escape  of  gas  or 
ingested  matter,  and  the  appearance  of  the  more  pronounced  symptoms 
of  perforating  wounds  of  the  alimentary  canal. 

Treatment. — When  a  wound  exists  in  the  wall  of  the  abdomen,  the 
immediate  indication  is  to  determine  whether  it  opens  into  the  cavity. 
In  order  to  do  this  tlie  disinfected  finger,  or  tlie  light  and  porcelain-tipped 
Iselaton  probe,  should  be   introduced,  and,  if  necessary,   the  opening 


526 


A  TEXT-BOOK   OX  SURGERY. 


should  be  enlarged.  Cocaine  anjesthesia  may  he  sufficient  for  this  prtv 
cedure.  If  the  wound  is  confined  to  the  abdominal  wall,  it  should  be 
treated  in  the  aseptic  method  advised  for  ordinary  wounds  of  the  soft 
tissues.  If  it  extends  throut,di  the  wall,  the  abdomen  shoidd  Ix^  opened, 
and  the  condition  of  the  viscera  examined.  As  to  whether  the  incision 
should  be  an  enlargement  of  the  accidental  wound,  or  made  in  the  median 
line,  the  location  and  direction  of  tlie  wound  must  determine.  The  sec- 
tion should  be,  preferably,  tlirough  the  linea  alba.  If  the  lesion  is  not 
more  than  six  inches  from  this  line,  and  if  the  direction  of  the  wound  is 
backward  or  tending  toward  the  center,  the  median  incision  should  be 
chosen.  Under  other  conditions  the  section  may  be  through  the  wound 
of  entrance. 

In  this  procedure  the  details  of  the  antiseptic  method  should  be  car- 
ried out,  as  directed  in  operation  for  the  relief  of  intestinal  obstruction. 
When  the  peritoneal  cavity  is  opened,  if  it  contain  clotted  blood  which 
is  known  not  to  have  entered  from  the  wound  of  operation,  or  ingested 
matter,  or  if  gas  escape  through  the  opening,  the  penetrating  character 
of  the  wound  is  evident.  If  none  of  these  signs  are  present,  the  disin- 
fected hand  sliould  l)e  introduced  and  the  internal  surface  of  the  wall 
examined  at  the  supposed  point  of  entrance.  In  examining  the  intestinal 
canal,  it  is  advisable  to  begin  with  the  loojxs  of  small  intestine  which  pre- 
sent at  the  incision.  These  should  be  carefully  drawn  out  throiigh  the 
opening,  and,  as  fast  as  inspected,  surrounded  with  towels  moistened  in 
warm  Thiersch  solution,  and  supported  in  the  hands  of  an  assistant,  who 
will  not  allow  them  to  drag  heavily  upon  the  exposed  mesentery.  If  an 
opening  be  found  in  the  gut,  it  may  be  at  once  closed,  or  noted  and 
passed  over  until  the  entire  canal  and  cavity  have  been  examined.     If  a 

cutting  or  puncturing  sharp  instrument  has 
inflicted  the  wound,  its  edges  will  be  found 
sufficiently  smooth  to  be  sutured  at  once. 


Fig.  549. — Pistol-shot  wound  of  small  intestine.     (After  Bull.) 


Fig.  M8. — Lembeit's  suture  for  clos- 
inj^  wounds  of  the  intestines. 
(Alter  Esmarch.) 


and  should  be  brought  together  by  Lem- 
bert's  suture  (Fig.  548).  If  the  hole  has  been 
made  by  a  bullet,  and  has  rough  and  torn  borders,  as  in  Fig.  .549,  its 
edges  should  be  trimmed  smooth,  with  curved  scissors,  and  then  closed. 
When  only  a  narrow  strip  of  tissue  separates  two  openings  (Fig.  549), 
they  should  be  converted  into  a  single  ellii)tical  wound,  and  sutured. 


WOUNDS  OF  THE  ABDOMEX.  527 

The  proper  distance  of  the  sutures  from  each  other  is  shown  in  Fig.  548. 
While  the  sutures  are  being  inserted,  the  intestine  sliould  be  laid  upon 
towels  spread  over  the  abdomen,  near  the  incision.  The  escape  of  fecal 
matter  into  the  cavity  of  the  peritonjenm  should  be  prevented  by  Hat 
syjonges  jilaced  around  the  margins  of  the  wound.  If  the  wound  in  the 
wall  of  the  gut  is  so  extensive  that,  in  closing  it,  the  lumen  of  the  tube 
will  be  seriously  constricted,  tlie  injured  portion  should  be  exsected. 
After  all  wounds  are  stitched  and  hfemorrhage  is  arrested,  the  cavity  of 
the  peritonfeum  should  be  carefully  cleansed.  This  is  effected  by  sponges, 
attached  to  holders,  carried  into  all  parts  of  the  cavity.  When  fecal 
extravasation  has  occuiTed,  it  will  be  advisable  to  fiood  the  entire  cavity 
with  warm  Tliiersch's  solution,  remove  it  with  sponges,  and  re])eat  the 
irrigation  until  the  liquid  comes  away  free  from  odor  or  color.  A  drain- 
age-tube should  be  employed  in  this  worst  class  of  cases.  The  Sims  tube 
is  to  be  preferred,  and  the  end  of  this  should  be  carried  down  to  the  most 
dependent  portion  of  the  cavitj^  (usually  in  the  pelvis,  in  the  cul-de-sac). 
The  method  of  employing  this  excellent  instrument  is  described  in  the 
article  on  ovarian  tumors. 

The  intestines  shoiild  now  be  returned  and  the  wound  closed.  Irriga- 
tion through  the  drainage-tube  may  be  made  when  indicated  by  the  tem- 
perature, tympanites,  etc. 

No  especial  treatment  can  be  laid  down  for  wounds  of  the  solid  viscera 
or  of  the  great  vessels.  The  arrest  of  hfemorrhage,  the  removal  of  ex- 
travasated  blood,  and  the  establishment  of  drainage  when  needed  are  the 
indications. 

The  argument  in  favor  of  operative  interference  in  penetrating  or 
supposed  penetrating  wounds  of  the  abdomen  may  be  briefly  stated,  as 
follows : 

1.  The  enlargement  of  a  wound  sufficiently  to  demonstrate  Its  opening 
(or  not  opening)  into  the  cavity  of  the  peritonaeum  is  a  simple  procedure, 
practically  without  danger. 

2.  Abdominal  section  is  not  a  difficult,  nor,  when  skillfully  and  prop- 
erly performed,  a  dangerous  operation. 

3.  A  penetrating  wound  of  the  abdcmien,  left  without  surgical  inter- 
ference, is  attended  always  with  great  danger. 

4.  If  any  vessels  of  size  are  divided,  haemorrhage  is  an  immediate 
danger,  and  peritonitis  a  serious  and  probably  fatal  complication. 

5.  If  the  alimentary  canal  is  opened,  death  is  almost  inevitable.  The 
few  recorded  cases  of  recovery  form  such  an  infinitesimal  proportion  of 
the  whole,  that  they  should  carry  no  weight  against  interference. 


CHAPTER  XVIII. 

PELVIC   ORGANS. 
HErrr.U  AXD   AXUS — OEXITO-VRIXARY   OlfOANS. 

Diseases  of  the  Rectum  and  Anus — Congenital  Defects. — Arrest  of 
development  in  the  rectal  and  anal  portions  of  the  alimentary  oaniil, 
though  not  so  frequent  as  at  the  upper  or  buccal  extremity,  is  unfortu- 
nately common  enough  to  justify  a  consideration  of  the  different  kinds 
of  deformity  which  may  here  be  met  with,  and  the  mode  of  treating 
them. 

Absence  of  the  anus  is  one  of  the  most  frequent  congenital  lesions  of 
the  alimentary  outlet.  The  rectum  may  be  partially  developed,  and  ter- 
minate within  the  pelvis  in  a  blind  pouch  at  a  point  more  or  less  re- 
moved from  the  normal  opening  (Fig.  550) ;  there  may  be  a  partial  de- 


Fio.  550. — Atresia  of  tlie  anus. 
(Atler  Esinaich.j 


Fig.  651. — Atresia  of  tlic  rectum,  witli  a  rudi- 
mentary anus.     (After  Esmaroh.) 


velopment  of  the  anus  (Fig.  551) ;  or  the  rectum  may  be  entirely  absent 
(Fig.  552) ;  or  it  may  be  ])resent  in  the  pelvis,  opening  abnormally  into 
the  bladder,  vagina,  uterus,  or  urethra  (Figs.  553  and  554).  In  the  sim- 
pler forms  of  atresia  ani  (/nly  a  thin  membrane  is  stretched  across  the 
otherwise  normal  opening.     The  more  complicated  varieties  are  those 


PELVIC   ORGANS. 


529 


in  which  a  greater  distance  intervenes  between  the  end  of  the  defective 
intestine  and  the  perinjEiim. 

Diagnosis. — Absence  of  the  anus  is  easily  established  l)y  inspection. 
The  more  important  and  difficult  point  is  to  determine  the  distance  from 


Fia.  552. — Atresia  of  the  anus  and  rectum. 
(After  Esmurch.) 


Fir.  553. — Atresia  of  tlie  anus  and  lower  portion 
of  tlie  rectum  ;  the  upper  |art  opening  into  the 
uretlua.     (After  Esmurch./ 


the  perinfBum  to  the  end  of  the  pouch. 
When  the  intervening  tissue  is  thin, 
the  accumulation  of  matter  within  the 
tube  may  cause  a  protrusion  in  the 
perineeum  which  is  exaggerated  when 
the  infant  cries.  If  the  finger  be 
pressed  into  the  perinanim,  an  ini- 
puLse  somewhat  comparable  to  that 
felt  in  the  expulsive  eiforts  of  a  pa- 
tient with  hernia  maybe  appreciated. 

Ex23loration  by  the  vagina,  when 
the  capacity  of  this  tube  will  permit, 
will  aid  in  diagnosis. 

When  the  intestine  oj^ens  into  an- 
other hollow  organ,  or  through  the 
integument  in  an  abnormal  position, 
the  only  diagnostic  sign  is  the  pres- 
ence of  fecal  matter  in  the  natural 
discharge  from  the  organ  or  at  the  abnormal  opening.  In  atresia  recti 
in  female  children,  the  bowel  opens  mo.st  frequently  into  the  uterus  or 
vagina,  and  in  males  into  the  bladder.  At  times  the  communication  is 
established  between  the  bowel  and  the  urethra,  or  a  false  opening  may 
occur  at  any  point  in  the  perinseum,  and,  in  rarer  cases,  in  some  remote 
portion  of  the  body. 
34 


Fig.  554. — The  same  j   tlie  upper  portion  of  the 


rectum   opening  into  the    bladder. 
Esiuarch.) 


(After 


530  A  TEXT-BOOK  ON  SURGERY. 

Treatment. — The  indications  are  to  establish  an  opening  as  near  the 
natural  position  of  the  anus  as  possible. ,  If  the  blind  pouch  can  be  reached 
by  the  exjilorin.c;  aspirator,  the  needle  should  be  left  in  ])lace  as  a  guide. 
The  operative  ])rocedure  is  to  dissect  gradually  toward  the  supposed 
location  of  the  end  of  the  gut,  keeping  an  open  and  clear  wound  by  using 
retractors  and  arresting  all  htPniorrhage.  The  incision  through  the  in- 
tegument should  be  in  the  median  line,  with  its  center  just  in  front  of 
the  tip  of  the  sacrum  and  coccyx,  for,  if  the  sphincter  ani  is  present, 
even  in  an  imi)erfect  condition,  it  is  important  to  preserve  it  to  aid  in 
the  voluntary  control  of  the  bowel  when  the  operation  is  completed. 
When  there  exists  only  a  thin  septum,  this  muscle  is  usually  well  de- 
veloped, and  the  operation  is  a  simjjle  incision  and  divulsion  of  the  mem- 
brane. In  more  formidable  operations,  the  location  of  the  urethra  and 
bladder,  and  in  females  the  vagina  and  uterus,  must  be  kei)t  well  in 
mind,  for  in  infants  the  pelvic  diameters  are  very  small,  varying  from 
one  to  one  and  a  half  inch.  It  is  a  safe  rule  to  proceed  cautiously 
along  the  sacral  curve.  Moreover,  it  is  wiser  to  dispense  with  an  an;es- 
thetic,  since  the  expulsive  efforts  in  crying  may  aid  in  linding  the  end 
of  the  gut. 

When  it  is  reached,  if  it  is  possible,  the  end  should  be  loosened, 
drawn  down,  and  sutured  to  the  integument  at  the  edges  of  the  incision. 
If  this  is  not  done,  the  opening  usually  contracts,  necessitating  repeated 
dilatation  by  the  use  of  the  linger,  tents,  or  a  divulsor.  In  some  in- 
stances it  has  been  found  necessary  to  remove  the  coccyx  in  order  to 
effect  the  union  of  the  bowel  with  the  skin. 

When,  after  proceeding  as  far  as  the  immediate  safety  of  the  infant 
will  justify,  the  bowel  can  not  be  discovered,  the  propriety  of  colostomy 
or  enterostomy  may  be  entertained.  If  determined  upon,  right  lumbar 
colostomy  is  indicated,  on  account  of  the  probability  of  absence  or  mal- 
position of  the  descending  colon.  When  the  intestine  ends  directly  in 
the  uterus  or  vagina,  and  there  is  no  ])ouching  behind  these  organs  to- 
ward the  perinseum,  it  is  best  not  to  interfere.  If,  however,  the  bladder 
or  urethra  is  involved,  an  opening  should  be  made  or  colostomy  per- 
formed. 

In  exceptional  cases  the  anus  is  present  in  a  condition  of  more  or  less 
perfect  develoinnent,  while  at  the  same  time  the  rectum  does  not  com-, 
municate  with  it,  but  terminates  in  a  blind  pouch  at  a  varying  distance 
from  the  perinpeum. 

The  effort  should  be  made  to  establish  a  communication  between  the 
two  pockets  by  dissection  through  the  tissues  which  intervene. 

When  the  opening  from  the  rectum  is  abnormally  small  (a  congenital 
stricture),  dilatation,  incision,  or  divulsion  should  be  performed. 

The  unfavorable  prognosis  in  all  these  cases  should  not  be  concealed. 
Inflammation,  visceral  complications,  dilatation  of  the  bowel  above  with 
retained  ingesta,  insufficient  assimilation,  pain,  etc.,  render  a  favorable 
issue  exceedingly  improbable. 

Pruritus  Ani. — Persistent  itching  about  the  anus  may  be  caused  by 
a  variety  of  skin-diseases,  as  eczema,  herpes,  pityriasis,  and  erythema, 


PELVIC  ORGANS.  531 

or  by  imtation  of  the  end-organs  of  the  sensory  nerves  from  over- dis- 
tention in  the  act  of  defecation.  It  is  also  a  symptom  of  heemorrhoids, 
fissure  of  the  anus,  or  may  be  due  to  the  presence  of  the  thread-worm 
{ascaris  vermicular  in).  The  character  of  the  itching  is  burning,  i;)ain- 
ful,  and  aggravating,  and  the  desire  to  scratch  is  almost  irresistible.  The 
successful  management  of  pruritus  ani  will  depend  upon  the  recognition 
of  the  disease  of  which  it  is  a  symptom. 

Eczema  of  the  peringeum  and  anus  is  more  apt  to  occur  in  a  warm 
temperature,  where  perspiration  is  excessive,  and  in  corpulent  individ- 
uals wheie  considerable  friction  o(;curs  between  the  folds  of  integument 
of  this  region.  The  skin  becomes  infiltrated  and  thickened,  fissures  are 
formed,  and  the  mucous  membrane  at  the  anal  opening  may  become  in- 
volved. 

Treatment. — The  part  affected  should  be  kept  clean  and  friction  pre- 
vented as  much  as  possible.  In  the  acute  eczema  of  the  anal  region  a 
■vvann  bath,  without  soap,  should  be  taken  two  or  three  times  a  day,  the 
parts  thoroughly  dried,  and  sprinkled  with  powdered  starch  or  lycopo- 
dium.  If  excoriations  exist,  lead-and-opium  wash  should  be  tried.  In 
chronic  eczema  of  the  anus,  in  order  to  effect  a  cure,  it  is  often  necessary 
to  remove  the  accumulation  of  scales  by  the  local  use  of  green  soap  for 
a  day  or  two,  and  then  smearing  the  surface  with  diachylon-salve. 

Herpes  may  be  recognized  by  the  character  of  the  eruption,  which  is 
vesicular,  the  vesicles  being  grouj^ed  in  bunches  around  the  anus.  Those 
which  rupture  and  are  subjected  to  irritation  present  flat  and  slightly 
ulcerating  excoriations.  The  treatment  consists  in  thoroughly  washing 
the  surface  involved  with  a  warm  solution  of  boracic  acid,  grs.  xv-  3  j 
of  water,  by  means  of  pellets  of  absorbent  cotton  moistened  in  the  solu- 
tion. This  should  lie  fullowed  by  applying  an  astringent  ointment,  com- 
posed as  follows :  plumbi  acetatis,  grs.  iij ;  acid,  tannic,  gr.  j  ;  niorphise 
sulph.,  grs.  iij;  adipis,  §j. 

Erythema  is  a  mild  foi-m  of  inflammation  f)f  the  integument,  occur- 
ring here  as  a  result  of  friction  between  the  folds  of  skin  of  the  two  sides 
and  the  irritation  from  perspiration  or  other  fluids.  The  warm  bath,  fol- 
lowed by  sprinkling  the  part  affected  with  starch  or  lycopodium,  will 
usually  effect  a  cure. 

Pityriasis  versicolor  occasionally  exists  in  the  ischio-rectal  region. 
This  disease  can  be  recognized  by  the  brownish  slate-color  of  the  parts 
involved.  The  cause  is  a  vegetable  parasite,  the  spores  and  mycelia  of 
which  may  be  easily  recognized  by  the  microscope.  It  yields  readilj"  to 
pure  sulphurous  acid,  which  may  be  applied  by  means  of  a  camel's-hair 
pencil.  Corrosive  sublimate  (gr.  j  to  water  5  j)  may  be  applied  by  wrap- 
X)ing  the  parts  with  absorbent  cotton  dipped  in  this  solution. 

When  pruritus  occurs  with  luemorrhoids  or  fissure,  the  treatment 
must  be  directed  to  these  affections.  If  it  is  caused  by  over-disteution 
or  irritation  of  the  rectum  and  anus,  the  use  of  enemata  and  laxatives 
will  arrest  the  disease.  The  local  application  of  a  4-per-cent  solution  of 
cocaine  hydrochlorate  will  dull  the  sensibility  of  the  part  and  tempo- 
rarily stop  the  jjain  and  itching. 


532  A  TEXT-BOOK  OX  SURGERY. 

Ascarides,  or  "  thread-worms,''  are  not  an  uncommon  cause  of  pru- 
ritus ani.  They  vary  in  length  from  a  quarter  to  half  an  inch,  are  some- 
what lighter  in  color  than  the  mucous  membrane,  and  are  not  readily 
seen  unless  this  membrane  is  everted  and  carefulh'  examined.  Santo- 
nin in  full  doses  should  be  administered  for  two  or  three  days,  followed 
by  a  free  purgation.  When  this  is  accomplished  the  bowel  should  be 
distended  \vith  an  enema  of  lime-water,  retained  for  lifteen  minutes,  if 
possible,  and  repeated.  As  soon  as  the  last  injection  is  evacuated,  a 
pint  of  water,  in  which  grs.  xx  of  carbolic  acid  are  thoroughly  dissolved, 
should  be  thrown  into  the  rectum  and  retained  for  about  five  minutes. 
The  injection  of  lime-water  and  carbolic  acid  in  solution  should  be  re- 
peated for  several  days  to  insure  a  thorougli  destruction  of  these  annoy- 
ing parasites. 

Enemata  of  the  infusion  of  quassia  are  also  highlj'  recommended  in 
the  extermination  of  the  ascaris  vennicularis. 

Forelfjn  Bndiea. — Foreign  bodies  in  the  rectum  are  usually  intro- 
duced through  the  anus,  and  not  infrequently  lodge  here,  having  passed 
through  the  alimentary  canal.  Their  presence  may  be  recognized  by 
digital  exploration,  or,  when  of  small  size,  the  speculum  may  be  em- 
ployed. 

Digital  exploration  of  the  rectum  may  be  performed  with  the  mini- 
mum of  discomfort  by  curving  the  thoroughly  lubricated  finger  to  con- 
form to  the  shape  of  the  lower  portion  of  the  bowel.     The  direction  from 

the  anus  is  upward  and  for- 
ward for  the  first  inch  and  a 
half,  and  then  upward  and 
slightly  backward. 

If  a  speculum  is  employed, 
that  of  Sims  (Fig.  555)  should 
be  preferred. 

A  small  body  may  be 
readily  removed  by  seizing 
it  Avith  a  long  forceps  after 
dilatation  with  this  instru- 
me«t.  A  large  substance  may  require  anaesthesia,  with  forcible  divul- 
sion  of  the  sphincter,  or  a  posterior  linear  rectotomy  before  it  can  be 
removed.  When  the  object  is  made  of  glass  or  any  fragile  substance, 
great  care  should  be  taken  to  prevent  its  breaking. 

Fistula  in  Ano. — A  fistula  of  the  anus  or  rectum  may  be  complete  or 
incomplete.  The  last  variety  is  further  divided  into  the  incomplete  ex- 
ternal and  the  incomplete  internal  fistula. 

In  the  complete  form  the  track  of  the  fistula,  more  or  less  sinu- 
ous, leads  from  the  wall  of  the  rectum  or  the  anal  margin  out  through 
the  integument  of  the  perineal,  ischio-rectal,  or  gluteal  regions  (Fig. 
556).  In  the  incomplete  external  variety,  the  track  opens  through  the 
skin,  but  does  not  communicate  with  the  rectum  (Fig.  5.57)  ;  while  m 
the  incomplete  internal  fistula  the  track  opens  into  the  bowel  only 
(Fig.  558). 


Sims's  rectal  speculum. 


FISTUXA  OF  THE  AXUS  AND  RECTUM.  533 

The  chief  causes  of  peri-rectal  abscess  are  the  irritation  which  follows 
the  lodgment  of  fecal  matter  and  undigested  substances  in  the  rectum  ; 

the  over-di-stention  of  this  organ  as  a  result  of  constipation  ;  the  presence 
of  hsemorrhoidal  tumors ;  the  introduction  of  hard  bodies,  as  the  nozzle 
of  a  syringe,  etc.,  through  the  anus  ;  and,  lastly,  dii-ect  injury  by  a  blow 
from  without.  Abscess  in  this  region  occurs  by  preference  in  the  weak 
and  debilitated,  in  those  suffering  from  the  tubercular  diathesis,  and 
is  rarely  met  with  before  the  twenty-lifth  year  of  life. 


Fig.  556. — Complete  tistula  Fig.  557. — Incomplete  external  Fig.  558. — Incomplete 

in  recto.  fistula.  internal  fiistula. 

Suppuration  begins  as  a  rule  in  the  loose  areolar  tissue  around  the 
rectum.  Although  the  inflammation  may  originate  in  the  mucous  mem- 
brane and  wall  of  the  bowel,  perforation  of  the  wall  is  rare  until  the 
process  of  suppuration  is  well  established  in  the  connective  tissues  of 
the  ischio-rectal  fossaJy  As  the  pus  accumulates  the  tissues  break  down, 
and  the  abscess  opens  into  the  bowel  or  through  the  integument.  A 
complete  fistula  may  be  developed  from  either  of  the  incomplete  varieties 
by  partial  occlusion  of  the  original  opening,  thus  causing  the  pus  to  seek 
an  outlet  elsewhere. 

Abscess  of  this  region  may  be  superficial  or  deep.  When  superficial, 
it  is  apt  to  open  through  the  mucous  membrane,  just  above  the  junction 
of  the  skin  and  mucous  membrane.  When  the  deep  variety  opens  into 
the  rectum,  it  is  usually  at  a  point  from  three  fourths  of  an  inch  to  two 
inches  from  the  margin  of  the  anus.  A  single  abscess. may  have  one  or 
more  openings  into  the  rectum  or  through  the  .skin. 

The  diagnosis  of  fistula  in  ano  is  not  diflicult.  It  depends  upon  the 
history  of  an  abscess  followed  by  a  constant  or  frequently  recurring  dis- 
charge of  pus,  the  pain  being  severe  until  the  abscess  is  evacuated,  and 
recurring  in  a  varying  degree  with  the  temporary  closure  of  the  out- 
let. An  area  of  induration  usually  exist.s,  and  the  opening  may  be  dis- 
covered either  through  the  skin  or  within  the  anus.  If  an  external 
opening  exists  through  which  gas  or  fecal  matter  escapes,  a  comjilete 
fistula  is  demonstrated.  When  an  external  opening  is  formed,  unless 
the  abscess  is  very  recent,  there  is  almost  always  an  internal  opening, 
although  it  may  not  be  found.  The  diagnosis  maybe  further  made  clear 
by  exploration  with  a  probe,  an  operation  which  is  rendered  ju-actically 
painless  by  the  injection  of  a  4-per-cent  solution  of  cocaine  hydrochlo- 
rate  into  the  abscess  cavity.  If  a  single  injection  does  not  suihciently 
dnll  the  sensibility,  it  should  be  repeated. 

No  matter  where  the  external  opening  is  situated,  the  track  will,  in 
the  great  majority  of  instances,  run  just  beneath  the  skin  toward  the 
anus.     The  probe  should  be  allowed  almost  to  find  its  own  way,  and. 


534  A  TEXT-BOOK  ON  SURGERY. 

when  well  in,  tlie  point  at  wliirh  it  impinges  upon  or  opens  into  the 
bowel  can  be  determined  by  the  linger  in  the  rectum. 

The  treatment  sliould  be  by  free  inci.sion.  In  mild  cases  local  anfes- 
thesia,  obtained  by  cocaine,  is  sufficient.  One  or  two  hypodermic  syringes 
f  uU  of  a  4-per-cent  solution  should  first  be  thrown  into  the  cavity  of  the 
sinus,  and  the  direction  of  the  opening  into  the  bowel  determined  by  the 
probe  or  grooved  director.  The  cocaine  should  then  be  injected  into 
the  tissues  by  repeated  introductions  tif  the  needle  in  the  line  of  the 
proposed  incision  into  the  bowel.  Thirty  minims  of  tliis  solution  are 
usually  sufficient  in  this  last  procedure,  but  as  many  as  sixty  may 
be  injected  if  necessary.  Of  the  quantity  thrown  into  the  abscess  only 
a  small  proportion  is  absorbed,  while  of  that  injected  into  the  tissues 
the  larger  part  escajjes  with  the  blood  which  follows  the  incision. 
When  the  sinus  is  long  and  the  cavity  of  the  abscess  extends  more  than 
one  inch  above  the  anus,  the  operation  should  be  performed  under  ether 
narcosis. 

Operation. — A  laxative  should  be  administered  the  day  before  the 
operation,  and  an  enema  given  two  hours  before  the  anajsthetic.  The 
perina?um  and  region  of  the  anus  should  be  cleanly  shaved.  The  patient 
should  be  placed  upon  the  back,  with  the  sacrum  resting  on  the  edge 
of  the  table,  the  legs  flexed  on  the  thighs,  and  the  thighs  on  the  abdo- 
men, and  separated  ;  or  upon  the  side  in  the  Sims  position.  Tlie  probe 
should  be  carried  into  the  fistula,  the  lubricated  index-finger  of  the 
left  hand  into  the  rectum,  and  the  point  noted  at  which  the  instrument 
strikes  the  rectum.  The  probe  is  now  withdrawn,  and  the  grooved  di- 
rector introduced  in  the  same  track.  If  the  opening  into  the  bowel  can 
not  be  found,  the  operator  should  determine  by  the  touch  the  thinnest 
point  on  the  intervening  wall,  and  at  this  location  bore  through  into  the 
rectum,  supporting  the  mucous  membrane  near  the  point  of  tlie  instru- 
ment with  the  finger  in  the  bowel.  As  soon  as  the  director  is  felt  in  the 
cavity  of  the  gut,  the  point  should  be  brought  out  at  the  anus,  the  sharp- 
pointed  curved  bistoury  carried  along  the  groove,  and  the  fistula  laid 
open  by  dividing  the  intervening  bridge  of  tissue.  If  a  second  sinus 
exists,  it  should  be  incised  in  the  same  way.  The  bleeding  is  usually 
in.significant,  and  may  be  arrested  by  pressure,  or  the  ligature.  The 
finger  should  now  be  carried  into  the  wound,  and,  if  it  is  discovered  that 
the  abscess  extends  higher  along  the  wall  of  the  rectum  than  the  point 
at  which  the  director  was  canied  through,  the  intervening  wall  should 
be  divided  with  the  blunt  scissors.  It  is  important  that  the  incision  in 
the  gut  should  extend  to  the  depth  of  the  abscess  when  this  point  is 
less  than  three  inches  from  the  anus.  A  careful  search  for  any  pockets 
or  sinuses  should  be  made,  and  these,  if  found,  shoiild  be  laid  freely 
open.  The  fi.stulous  track  should  now  be  scraped  out  with  the  sharp 
spoon,  and  the  entire  wound  packed  with  sublimate  gauze  held  in  place 
by  a  compress  and  T-bandage.  This  dressing  should  be  allowed  to  re- 
main in  place  for  two  or  three  days,  when,  %vith  the  first  evacuation  of  the 
bowels,  it  is  carried  away.  After  this  the  wound  is  not  repacked,  but, 
for  purposes  of  cleanliness,  it  may  be  washed  out  by  allowing  the  patient 


FISTULA    OF  THE  AXTJS  AND   RECTUM.  535 

to  sit  in  a  basin  of  warm  water  once  or  twice  a  day,  or  by  irrigation,  and 
an  outside  dressing  applied. 

The  wound  rajiidly  lieals  by  granulation,  and,  in  the  vast  majority 
of  cases,  a  cure  is  effected  by  a  single  operation.  Temporary  inconti- 
nence of  f feces  results  in  all  oases  whei"e  both  sphincters  are  divided,  but 
a  permanent  loss  of  function  is  exceptional.  It  is  more  apt  to  occur  in 
females,  and  for  this  reason  a  more  guarded  prognosis  should  be  made 
in  this  class  of  patients.  In  the  rare  instances  in  which  an  internal  in- 
complete fistula  is  present,  the  ca\'ity  of  the  abscess  should  be  opened 
by  incision  through  the  skin,  and  the  operation  completed  as  just  given. 

A  division  of  the  external  sijhincter  is  not  necessary  in  the  mildest 
class  of  cases,  in  which  the  abscess  is  recent  and  small,  and  in  which  the 
sinus  runs  just  beneath  the  skin  and  opens  at  the  margin  of  the  anus. 
Under  all  other  conditions  it  should  be  partially  or  completely  divided. 

The  immediate  closure  of  the  fistulous  track  is  an  operation  which 
has  been  recently  perfonmed  in  a  number  of  instances.  After  the  fistula 
is  incised,  the  wall  of  the  abscess  is  dissected  out  and  the  two  perfectly 
healthy  surfaces  are  brought  together  with  sutures. 

An  older  method  consists  in  the  introduction  of  an  elastic  ligature 
through  the  external  opening  into  the  bowel  and  out  through  the  anus, 
where  the  ends  are  tied  together.  The  loop  is  allowed  to  cut  through 
slowly,  and  it  may  be  necessary  to  tighten  it  from  time  to  time. 

Prophylaxis. — Upon  the  first  appearance  of  inflammation  in  the 
ischio-rectal  or  perineal  region,  the  integument  immediately  over  the 
most  supei-ficial  point  of  the  induration  should  be  incised,  and  a  free 
puncture  made  into  the  inflamed  tissues.  This  should  be  followed  by 
the  application  of  poultices  and  complete  rest  in  the  recumbent  post- 
ure. Too  great  distention  of  the  rectum  should  be  prevented  by  the 
administration  of  laxatives,  and  an  enema  of  warm  water  should  be 
given  just  before  the  bowel  is  emptied.  By  this  method  the  tension  is 
relieved  and  an  outlet  given  to  the  products  of  inflammation  before  the 
process  extends  into  the  deeper  tissues.  A  cure  without  further  opera- 
tion will  be  effected  in  a  fair  proportion  of  cases. 

After  an  abscess  is  once  formed,  whether  the  fistula  opens  into  the 
rectum  or  through  the  integument,  or  has  lioth  oixtlets,  the  case  demands 
operative  interference.  Tlie  proportion  of  cures  by  the  use  of  injections 
into  the  fistula,  or  the  application  of  stimulating  remedies,  is  so  very 
small  and  such  valuable  time  is  lost,  that  their  employment  is  unjusti- 
fiable. Of  the  radical  operations,  preference  should  always  be  given  to 
that  of  free  incision.  The  elastic  ligature  should  only  be  tried  on  pa- 
tients who  are  unwilling  to  remain  in  bed,  or  to  be  operated  upon  with 
the  knife,  to  whom  the  merits  of  the  two  operations  have  been  explained, 
and  who  relieve  the  surgeon  of  the  probabilities  of  failure.  It  is  also 
applicable  to  those  cases  in  which  the  fistula  enters  the  rectum  so  high 
up  that  incision  is  impracticable.  A  guarded  prognosis  should  be  made 
in  this  class  of  patients. 

Operation  by  immediate  closure  should  not  be  preferred  to  the  open 
method,  for  the  reasons  that  the  old  operation  cures  almost  all  cases, 


536  A  TEXT-BOOK   ON   SURGERY. 

and  is  easy  of  execurion.  The  new  method  is  more  difficult,  and  is  only 
applicable  to  the  milder  cases.  The  failure  to  close  even  a  small  part  of 
the  wound  in  the  rectal  wall  wf)uld  insure  failure,  while  a  like  result 
would  be  apt  to  follow  if  the  entire  wounded  surfaces  were  not  in  perfect 
coaptation.  This  operation  would  be  applicable  in  those  cases  where,  as 
a  result  of  incision,  there  was  serious  impairment  in  the  function  of  the 
sphincter  ani. 

Operative  interference  is  contraindicated  in  multiple  fistulse  in  the 
aged,  or  in  patients  in  a  weak  and  debilitated  condition.  When  the 
tubercular  diathesis  is  well  marked,  an  operation  should  not  be  done 
unless  great  discomfort  is  caused  by  the  fistula,  and,  when  performed, 
the  prognosis  should  be  guarded. 

Fisgiire. — Fissure  of  the  anus  is  most  frequently  met  with  on  the 
posterior  portion  of  the  outlet.  It  may,  however,  exist  at  any  part  of 
the  anal  circumference,  or  in  the  rectum  above  the  sphincter.  The  tear 
is  usually  through  the  mucous  membrane,  although  the  muscular  fibers 
may  be  more  or  less  involved.  The  chief  cause  is  over-distention  of  the 
anus  in  the  evacuation  of  hardened  faeces,  together  with  the  presence  of 
sharp  substances  in  the  matter  discharged.  In  like  manner,  foreign 
bodies  introduced  into  the  rectum  may  produce  it.  Fisstire  may  result 
from  the  inflammation  and  ulceration  of  a  hsemorrhoid,  or  from  any 
chronic  inflammatory  process  in  the  rectum. 

The  chief  symptom  is  pain  of  an  acute  character,  exaggerated  by  an 
evacnation  of  the  bowel,  and  continuing  some  time  after  the  act  in  a 
violent  spasm  of  the  sphincter  muscle.  By  careful  and  gentle  dilata- 
tion of  the  anus,  it  may  be  seen  or  recognized  by  the  touch  as  a  line  of 
induration  running  parallel  with  the  axis  of  the  bowel.  The  employment 
of  cocaine  wiU  render  the  exploration  more  thorough,  and  will  permit 
the  introduction  of  the  speculum. 

Treatment. — ^The  administration  of  laxatives,  and  the  employment  of 
enemata  of  warm  water  and  olive-oil,  will  remove  the  chief  source  of 
irritation,  while  the  stimulating  effect  of  the  lunar-caustic  pencil  applied 
in  the  fissure,  and  repeated  every  two  or  three  days,  will  usually  effect  a 
cure.  Cocaine  should  be  employed  to  deaden  the  sensibility  before  the 
silver  is  applied.  If  a  more  radical  procedure  is  necessary,  it  will  con- 
sist in— 1,  a  partial  division  of  the  sphincter  in  the  line  of  the  fissure ; 
or,  2,  temporary  paralysis  of  this  muscle  by  divulsion. 

As  the  second  operation  requires  ether  narcosis,  the  i:)artial  division 
should  be  first  emjjloyed.  In  its  performance  local  ansesthesia  should 
be  obtained  by  the  ax>plication  of  4-per-cent  cocaine  to  the  inflamed  sur- 
face, together  with  the  injection  of  this  fluid  by  introducing  the  needle 
just  beneath  the  fissure  in  its  entire  extent.  The  sphincter  should  now 
be  made  tense  by  .separating  the  sides  of  the  speculum,  and  an  incision 
made  through  the  depth  of  the  fissure,  dividing  about  half  of  the  thick- 
ness of  the  muscle.  In  the  after-treatment,  the  bowels  should  be  kept 
open.  Divulsion  of  the  sphincter  is  performed  as  follows :  The  patient, 
fully  anfesthetized,  is  placed  upon  the  back,  with  the  thighs  separated 
and  flexed  on  the  abdomen.     The  operator,   having  lubricated  both 


FISSURE   AND  ULCER  OF  THE  ANUS  AND  RECTUM.       537 

thumbs,  introduces  one  and  then  the  other  to  their  full  length,  and 
stretclies  the  opening  directly  to  the  right  and  left  until  the  palmar  as- 
pect of  each  thumb  is  in  contact  Avith  the  inner  surface  of  the  tuber 
ischii.  A  towel,  held  in  place  by  a  roller  or  T-bandage,  should  be  applied 
to  prevent  soiling.  The  rest  obtained  by  the  paralysis  of  the  sphincter 
allows  the  fissure  to  heal.  The  function  of  the  muscle  is  restored  in 
from  eight  to  twelve  days. 

Ulcers. — The  traumatic  causes  of  ulcer  of  the  rectum  are  the  same 
as  those  given  for  fissure  of  the  anus.  Ulcer  may  also  result  from  any 
acute  or  chi-onic  inflammatory  process  of  the  lower  bowel.  It  is  a 
not  infrequent  sequence  of  dysentery,  and  may  be  met  with  in  that 
form  of  proctitis  which  results  from  prolonged  diarrhcea.  Inflamma- 
tion of  a  hsemorrhoidal  tumor  will  produce  ulcer  of  the  rectum,  and 
the  same  is  true  of  the  gummatous  deposits  of  the  late  stages  of  syph- 
ilis. A  primary  chancre  or  a  chancroid  may  be  located  at  the  anal 
margin,  and  less  frequently  in  the  bowel.  These  two  varieties  of  ulcer 
are  usually  seen  in  women  sufi'ering  with  pudendal  chancre  or  chan- 
croid, and  in  males  the  subjects  of  pederasty.  Tubercular  deposits  in 
the  rectum  may  also  break  down,  and  thus  cause  ulceration  in  the  wall 
of  this  organ. 

The  sj^mptoms  of  iilcer  of  the  rectum  vary  with  the  character  of  the 
sore  and  with  its  location.  If  the  lesion  is  sitxiated  within  the  grasp  of 
the  sphincter  muscles,  tenesmus  is  apt  to  be  a  marked  feature.  The 
ulcer  from  a  traumatism,  or  following  an  acute  inflammatory  process, 
is  more  apt  to  be  painful  than  that  which  is  a  part  of  a  subacute  or 
chronic  catarrh,  or  which  occurs  with  tuberculosis  or  syphilis.  A  com- 
mon symptom  of  all  ulcers  of  this  organ  is  the  presence  of  more  or  less 
blood  and  mucus  or  pus  in  the  discharges.  The  diagnosis  may  be  con- 
firmed by  inspection  with  the  speculum,  and  by  digital  exploration. 
Tubercular  ulcer  of  the  rectiim  very  rarely  exists  before  the  symptoms 
of  deposits  in  the  lungs  are  present.  Upon  inspection  they  are  recog- 
nized by  their  yello\vish  color,  usually  small  size,  and  their  dissemina- 
tion over  a  considerable  area  of  the  mucous  membrane.  In  the  more 
fully  developed  ulcers  the  caseous  degeneration  of  the  inflammatory 
products  may  be  observed. 

Mr.  Allingham  describes  a  rare  form  of  ulcer  which  he  has  occasion- 
ally observed  in  the  rectum,  and  which  he  has  named  lupoid,  or  rodent 
ulcer,  of  this  organ.  Its  usual  location  is  near  the  anus.  It  tends  to 
spread  widely,  the  floor  of  the  ulcer  is  red  and  diy,  the  margins  irregular 
and  precipitous.     It  is  very  probably  tubercular  in  character. 

Cliancroidal  ulcer  of  the  rectum  may  be  recognized  by  the  precipitous 
margins  of  these  sores,  and  by  the  rapidity  with  which  they  spread. 
In  patients  affected  with  phagedenic  ulcers  of  the  genital  organs,  the 
inoculation  may  occur  by  direct  ccmtact  of  the  secretion  of  the  venereal 
sore,  or  the  virus  may  be  conveyed  through  the  medium  of  the  nails  in 
the  act  of  scratching.  Under  such  conditions  the  sore  usually  first  ap- 
pears upon  the  mucous  membrane  of  the  margins  of  the  anus,  and  ex- 
tends later  into  the  rectum.     The  diagnosis  must  be  based  upon  the 


538  A  TEXT-BOOK   ON  SURGERY. 

peculiar  appearance  of  tlu'  ulcer,  together  with  the  probabilities  of  in- 
fection from  a  contiguous  venereal  ulcer. 

Tlie  hard  syi)liiHtic  or  true  <'hancre  is  rarely  observed  in  tliis  region, 
and,  when  met  with,  is  usually  conlined  to  the  anal  margin.  It  possesses 
here  the  same  well-recognized  features  of  the  specific  \ilcer  of  the  genital 
organs,  fiom  which  source  the  virus  is  conveyed  usually  by  the  nails, 
and  occasionally  by  immediate  coutagion. 

Ulcers  of  the  rectum  resulting  from  the  breaking  down  of  the  gumma- 
tous dejiosits  of  tertiary  syphilis  are  chiefly  seen  just  along  the  upper 
margin  of  the  sphincter  muscle.  From  this  i)()int  they  extend  upward, 
and  may  involve  the  entire  rectum  and  invade  the  colon.  These  ulcers 
are  usually  multiple,  varying  in  size  from  a  small  point  to  a  half-inch 
or  more  in  diameter,  and  in  depth  may  involve  only  the  mucous  mem- 
brane, or  the  muscular  and  connective-tissue  stroma  may  be  destroyed, 
and  in  some  instances  perforation  may  occur.  The  pi-ocess  of  destruc- 
tion is  greater  in  the  older  ulcers,  and  the  various  stages  may  be  observed 
by  examining  the  bowel  from  below  upward.  The  appearance  of  the 
ulcers  as  above  described,  together  with  the  history  of  syphilis,  will  en- 
able the  observer  to  arrive  at  a  correct  diagnosis.  Traumatic  ulcers,  and 
those  resulting  from  the  breaking  down  of  hiemorrhoidal  tumors,  will 
be  recognized  by  the  appearance  of  the  sore  and  the  history  of  an  acci- 
dent or  haemorrhoids. 

As  far  a3  a  cure  of  the  ulcer  is  concerned,  a  favorable  prognosis 
may  be  made  in  all  ulcers  of  the  rectum  except  the  tubercidar.  These 
may  be  relieved  by  treatment,  but,  being  expressions  of  an  incurable 
dyscrasia,  permanent  relief  can  not  be  expected.  A  more  remote, 
as  well  as  greater  evil  which  often  results  from  ulcer,  is  stricture  of 
the  rectum,  and  the  danger  of  stricture  is  usually  proportionate  to 
the  extent  of  the  destructive  process.  Phagedenic  chancroidal  ulcer, 
and  the  ulcers  of  gumma  and  dysentery,  are  esi^ecially  prone  to  induce 
stricture. 

Treatment. — The  common  indication  in  the  treatment  of  all  forms  of 
ulcer  of  the  rectum  is  to  keep  the  bowel  in  as  complete  repose  as  possi- 
ble. Every  effort  should  be  made  to  keep  it  clear  of  fecal  matter.  This 
may  be  accomplished  by  the  repeated  employment  of  enemata,  and  by 
the  administration  of  proper  articles  of  diet,  all  of  which  should  be 
capable  of  absorption  in  the  stomach  and  small  intestines.  Milk,  beef- 
tea,  meat-juice,  soft-boiled  eggs,  wine-jelly,  rice,  corn-meal  mush,  etc., 
will  afford  variety  and  sustain  the  patient's  nutrition. 

In  irrigation  of  the  diseased  surface,  warm  or  cold  water  may  be  used 
at  the  temperature  which  is  most  agreeable  to  the  patient.  The  best 
apparatus  for  this  purpose  is  the  fountain-syringe.  The  smallest  glass 
nozzle,  thoroughly  warmed  and  oiled,  should  be  employed,  and  from  one 
to  two  pints  of  fluid  may  be  introduced  at  one  injection.  A  larger  quan- 
tity may  be  employed  when  the  colon  is  involved.  If  the  patient  is 
placed  upon  the  left  side,  with  the  buttocks  elevated,  a  greater  degree 
of  tolerance  will  be  obtained  in  the  rectum.  The  fluid  should  be  re- 
tained for  a  few  minutes,  if  jjossible. 


ULCER  AND   STRICTURE   OF  THE  RECTUM.  539 

When  the  ulcer  encroaches  upon  the  sphincter  muscle,  causing  pain- 
ful tenesmus,  the  hypodermic  use  of  morphia  or  opium  suppositories 
may  be  required  to  relieve  the  spasm.  In  obstinate  cases  divulsion  or 
division  of  the  sphincter  may  be  done  as  a  last  resort. 

In  the  treatment  of  the  ulcers  which  result  from  dysentery,  catarrh 
of  the  rectum,  an  injury,  or  breaking  down  of  hsemori'hoids,  the  plan 
just  given  should  be  adopted.  It  is  often  advisable  to  add  from  gi-s.  v-x 
of  nitrate  of  silver  to  the  pint  of  water  thrown  in,  and,  if  the  vilcer  can 
be  reached,  recovery  will  be  hastened  by  the  local  use  of  the  lunar  caus- 
tic. An  excellent  remedy  for  the  alleviation  of  pain  and  the  relief  of 
tenesmus  is  a  suppository  composed  of  gr.  ij  each  of  iodoform  and  co- 
caine hydrochlorate,  introduced  from  three  to  five  times  in  twenty-four 
hours.  As  already  stated,  in  obstinate  and  extreme  cases,  lumbar  coloto- 
my  may  be  necessitated . 

Chancroidal  ulcer  of  the  rectum  requires  the  most  energetic  treat- 
ment. Ether  should  be  administered,  the  sphincter  divulsed,  the  ulcer 
exposed  by  the  speculum,  its  surface  scrajjed  with  the  curette,  and  a 
thorough  cauterization  eifected  with  nitric  acid.  The  cocaine  and  iodo- 
form suppositories  should  be  employed  in  the  after-treatment. 

True  syphilitic  chancre  of  the  rectum  rarely  demands  local  treat- 
ment. It  yields  readily  to  the  constitutional  remedies  emj^loyed  in 
syphilis. 

The  specific  ulcer  of  the  later  stages  of  syphilis  requires  the  consti- 
tutional treatment  recommended  for  the  late  manifestations  of  this  dis- 
ease, and  locally,  imgation  and  the  cocaine  and  iodoform  suppositories. 

Tubercular  ulcers  should  be  treated  chiefly  by  the  administration  of 
cod-liver  oil  emulsion,  the  iron  tonics,  the  hypophosphites  of  lime  and 
soda,  and  carefully  selected  diet.  Irrigation  with  warm  water  will  be 
found  useful.  AVhen  pain  and  tenesmus  exist,  relief  may  be  obtained 
by  the  means  already  given. 

In  rodent,  or  lupoid  ulcer,  the  Paquelin  cautery-knife  should  be  em- 
ployed, and  a  thorough  excision  of  the  diseased  surface  efi'ected. 

Stricture  of  the  Rectum. — Stricture  of  the  rectum  may  be  congenital 
or  acquired.  Partial  and  complete  congenital  occlusion  of  this  organ  has 
already  been  considered.  Acquired  stricture  is  usually  the  result  of  an 
inflammatory  process  in  the  walls  of  the  rectum,  and  at  times  in  the  tis- 
sues which  surround  this  oi-gan  (Fig.  5.59).  New  formations  (cancer, 
etc.)  may  also  cause  a  partial  or  complete  occlusion  of  the  rectum,  not 
only  by  reason  of  the  bulk  of  the  cells  proper  of  the  neoplasm,  but  on 
account  of  the  inflammatory  process  which  it  causes  in  the  connective- 
tissue  elements  of  the  bowel. 

The  lumen  of  this  portion  of  the  intestine  may  be  partially  or  com- 
pletely occluded  by  pressure  of  a  tumor  not  connected  with  the  bowel, 
or  by  the  presence  of  some  displaced  organ,  as  the  uterus,  bladder,  etc. 
Lastly,  spasmodic  stricture  may  occur  from  contraction  of  the  circular 
muscular  fibers  of  the  rectum. 

As  stated  on  a  previous  page,  organic  stricture  frequently  follows 
ulcer  of  the  rectum,  and  is  esi^ecially  apt  to  occur  in  the  ju'ocess  of  cica- 


540 


A  TEXT-BOOK   ON  SURGERY. 


trization  after  dysenteric  uletrs  aiul  those  of  the  tertiary  stage  of  syi)lii- 
lis.     The  accidents  of  parturition  not  infrequently  tend  to  stricture,  and 

this  may  afcount  for  tlie  <;r(':it('r  prevalence 
of  this  lesion  in  females  than  in  males. 

Stricture  of  the  rectum  may  be  narrow 
or  linear,  or  hirir/nnA  tortuous.  The  usual 
location  is  about  two  inches  above  the  mar- 
gin of  the  anus,  although  any  part  of  the 
organ  may  be  involved.  The  earlier  sym])- 
toms  of  this  lesion  are  inteiftrence  with  the 
act  of  defecation,  pain  with  the  passage  of 
fgeces,  and  the  presence  of  blood  or  mucus 
in  the  discharges.  In  some  instances  the 
fajces  are  tape-like,  or  are  al)normally 
shaped,  although  this  symjjtom  may  not  be 
])rpsent  when  the  stricture  is  high  up,  since 
the  fecal  matter,  after  it  passes  through  the 
constriction,  may  assume  the  shape  of  the 
bowel  below.  If  the  constriction  is  situ- 
ated within  the  first  four  inches  of  the 
bowel,  its  presence  and  caliber  may  be  de- 
termined by  digital  exploration.  When 
with  difficulty  reached  by  the  finger,  the 
patient  should  be  directed  to  strain  as  if 
at  stool,  in  order;  to  force  the  obstruction 
nearer  the  anus.  Beyond  this  limit  the 
bulbous  bougies  must  be  relied  upon.  These  instruments  are  of  all  sizes, 
each  consisting  of  an  oval  bulb  of  hard  rubber,  attached  to  the  end  of 
a  flexible  whalebone  staff.  In  introducing  them  the  patient  should  rest 
upon  the  back  while  the 
bougie,  warmed  and  oiled, 
is  guided  up  the  bowel, 
upon  the  index-finger  of 
the  left  hand,  which  is 
carried  its  full  length  into 
the  rectum  (Fig.  500).  If 
resistance  is  met  with, 
only  careful  and  gentle 
pressure  should  be  ex- 
ercised, for  undue  vio- 
lence may  drive  the  l)ulb 
through  the  wall  of  the 
gut.  The  inferior  limit 
of  the  stricture  is  indi- 
cated by  the  first  obstruc- 
tion encountered.  If  the  bulb  can  be  carried  through  the  constriction, 
the  resistance  ceases,  but  is  again  experienced  when,  upon  withdrawing 
it,  the  shoulder  of  the  instrument  catches  at  the  upper  limit  of  the 


Fig.  559.— Stricture  of  tho  rectum  from 
connective-tissue  new-formation  in 
tlie  auhmucous  layer.   (After  Bushe.) 


Fig.  600. — Method  of  intrnducins  the  hulljous  bougie  in  explora- 
tion ot  the  rectum.     (After  Bushe.) 


STRICTURE   OF  THE   RECTUM. 


541 


obstruction.  The  lower  border  of  the  stricture  is  again  indicated  when 
all  resistance  ceases  in  withdrawing  the  bulb. 

Treatment. — The  surgical  treatment  of  stricture  of  the  rectum  may- 
comprise  dilatation  or  division  of  the  cicatricial  tissue  or  colotomy. 

The  character  of  the  obstruction  and  its  location  will  deteiTnine  the 
means  to  be  employed.  When  the  stricture  is  linear,  and  is  located 
near  the  anus,  relief  may  be  obtained  by  dilatation.  For  this  purpose 
the  finger  should  be  employed,  and  the  operation  repeated  at  necessary 
intervals  until  a  sufficient  opening  is  secured.  If  the  cicatricial  tissue 
is  dense,  and  does  not  yield  in  the  effort  at  dilatation,  it  should  be  in- 
cised to  a  slight  depth  at  four  or  five  points  of  its  circumference,  and 
the  finger  again  introduced.  The  incisions  may  be  made  with  a  probe- 
pointed  bistoury,  carried  along  the  finger  as  a  guide,  or  the  anus  and 
bowel  may  be  stretched  with  the  Sims  rectal  speculum  up  to  the  point 
of  obstruction,  and  the  knife  introduced  without  a  guide.  If  this  pro- 
cedure is  not  successful,  the  only  alternative  is  posterior  linear  rectoto- 
my.  In  i^erforming  this  operation  the  patient  is  jilaced  upon  the  back, 
with  the  anus  at  the  edge  of  the  table,  and  the  legs  drawn  up  and  sepa- 
rated. The  parts  below  the  obstruction  are  dilated  with  the  speculum. 
A  long,  curved,  sharp-pointed  bistoury  is  carried  through  the  stricture, 
keeping  the  ciitting  edge  toward  the  posterior  median  line  of  the  gut. 
As  soon  as  the  point  is  beyond  the  obstruction,  hut  not  more  than  four 
inches  from  the  anus,  it  is  carried  through  the  wall  of  the  bowel,  which, 
with  the  stricture,  is  completely  divided  out  through  the  anus.  If  the 
first  incision  does  not  permit  the  introduction  of  the  first  two  fingers 
side  by  side,  it  should  be  made  deeper.  Hsemorrhage  is  readily  stopped 
by  packing  the  wound  and  bowel  with  gauze,  taking  the  precauticm  to 
insert  a  stiff  rubber  tube  in  the  middle  of  the  dressing  to  allow  the 
escape  of  gas  from  the  intestine.  If  any  important  vessel  is  divided, 
it  may  be  secured  with  the  forceps  or  by  transfixion  with  a  tenaculum. 
The  dressing  is  allowed  to  remain  in  place  for  four  or  five  days,  and 
is  not  replaced  after  the  bowels  are  moved  unless  bleeding  should 
occur.  Continence  of  ffeces  is  restored  after  from  three  to  six  weeks. 
No  matter   how   thoroughly  divided,    the   tendency  is  to  recurrence, 


Fio.  561. — Soft-rubber  rectal  bougies  (twelve  sizes). 


which  necessitates  interrupted  dilatation  at  intervals  of  from  three 
to  six  weeks  during  the  life  of  the  patient.  It  is  iisually  not  neces- 
sary to  practice  dilatation  within  the  first  six  or  eight  weeks  after  the 
operation. 


542  A  TEXT-BOOK  ON  SURGERY. 

When  the  stricture  is  situated  more  than  four  inches  above  the  anus, 
rectotomy  is  not  permissible  on  account  of  the  proximity  of  the  hirge 
li.Tmorrhoidal  vessels,  the  peritonaeum,  and  pelvic  fascia.  Dilatation 
with  the  soft-rubber  bougies  (Fig.  nOl)  may  be  tried,  and,  if  this  fails,  a 
rectotomy  may  be  done  as  high  as  the  limit  already  given,  which  will 
allow  the  introduction  of  the  hand  to  tliis  point  and  the  finger  into  the 
stricture.  This  may  now  be  nicked  with  the  bistoury,  as  above  de- 
scribed, and  digital  or  instrumental  dilatation  eifected.  Rectal  bougies 
before  being  iised  should  be  made  thoroughly  tl('xil)le  by  immersion  in 
warm  water.  In  their  employment  only  a  mild  degree  of  force  should 
be  exercised,  for  fear  of  perforating  the  wall  of  the  intestine. 

When  all  other  measures  fail,  left  lumbar  colotomy  is  the  last  resort. 


Neoplasms  of  the  Rectum  and  Axus. 

Carcinoma. — Of  the  malignant  new  formations  which  are  found  in 
this  organ,  epitlieliovia  is  the  most  common,  .sclrrhus  and  encephaloid 
cancer  being  next  in  order  of  frequency.  The  latter  is  comparatively 
rare.  Cancer  of  the  rectum  occurs  about  equally  in  the  sexes,  and 
almost  always  in  the  middle-aged  and  old,  although  in  exceptional  in- 
stances it  has  been  observed  before  the  age  of  twenty-five. 

Epithelioma  begins  in  the  mucous  membrane,  scirrhus  and  encepha- 
loid carcinoma  in  the  submucous  tissues. 

The  former  is  slower  in  development  and  less  apt  to  recur  after  re- 
moval. The  most  common  location  (jf  cancer  of  the  lower  bowel  is  at 
the  upjier  margin  of  the  sphincter  muscle. 

The  prognosis  is  grave,  the  duration  of  life  varying  from  one  to  two 
or  three  years,  and  in  exceptional  cases  longer.  Usually  the  earliest 
symptom  of  cancer  of  the  rectum  is  pain  with  the  act  of  defecation.  If 
the  disease  is  located  at  the  margin  of  the  anus,  it  can  be  recognized 
before  there  is  any  interference  with  the  discharge  of  fecal  matter. 
Later,  hsemorrhage  is  of  frequent  occurrence,  although,  as  a  rule,  it  is 
not  profuse  in  character.  After  an  evacuation  of  the  contents  of  the 
bowel,  the  pain,  though  less  intense,  remains  for  some  time.  A  sense 
of  fullness  or  "  bearing  down"  is  a  marked  feature  of  this  disease  in  the 
majority  of  cases. 

D/'ar/nosis. — If  operative  interference  is  to  be  imdertaken,  it  is  im- 
portant that  an  early  diagnosis  be  made.  Epithelioma,  as  has  been 
said,  begins  in  the  mucous  membrane,  the  cells  of  the  new  formation 
break  down  early,  the  ulcer  being  present  in  some  instances  before 
there  is  marked  induration.  On  the  other  hand,  induration  and  thick- 
ening are  observed  early  in  the  history  of  scin-hus  and  encephaloid. 

Non-malignant  stricture  of  the  rectum  is  always  preceded  by  a  his- 
tory of  chronic  infiauimation.  To  the  touch,  the  cicatricial  character  of 
the  tissue  may  be  recognized  by  its  firmness  and  sharp  borders.  It  is 
not  nodular,  like  cancer,  nor  is  there  a  deep  and  wide  infiltration  of  the 
suiTounding  tissues  in  simple  stricture,  which  condition  is  common  to 


NEOPLASMS   OF  THE   RECTUM  AND  ANUS.  543 

scirrliiis  and  encephaloid,  and  the  later  stages  of  epithelioma.  In  doubt- 
ful cases  it  will  be  advisable  to  remove  a  portion  of  the  mass  for  micro- 
scopical examination. 

The  treatment  of  cancer  of  the  rectum  may  be  palliative  or  radical. 
The  fomier  looks  to  the  prolongation  of  life  and  the  alleviation  of  pain 
by  the  employment  of  careful  dietetic  and  medicinal  measures.  The 
regular  daily  introduction  of  warm  water  will  prevent  the  lodgment  of 
fecal  matter  and  secure  the  greatest  possible  immunity  from  iiTitation. 
The  iodoform  and  cocaine  suppositories  will  be  found  useful  in  alleviat- 
ing pain,  and  morphia  may  be  employed  if  all  other  measures  fail.  As 
the  disease  progresses  it  will  be  found  necessary  to  practice  dilatation 
of  the  stricture  at  intervals  which  should  be  as  far  removed  as  possible, 
or  partial  or  complete  division  niaj'  be  required. 

The  radical  treatment  consists  in  the  free  excision  of  the  neoplasm. 
The  death-rate  after  this  operation  is  exceedingly  heavy,  and,  when  the 
dissection  is  extensive  and  recovery  follows,  the  condition  of  fecal  in- 
continence is  deplorable.  Moreover,  the  tendency  to  recurrence  is  so 
great  that  this  knowledge  should  deter  the  surgeon  from  undertaking 
the  operation  in  other  than  the  mildest  cases.  "When  the  disease  extends 
higher  than  three  inches  from  the  anus,  it  is  of  doubtful  propriety,  ami 
in  scu'rhus  and  encejjhaloid  cancer,  on  account  of  the  rapid  and  wide 
intiltration  which  occurs  with  these  neoplasms,  the  operation  does  not 
offer  a  prospect  of  relief  sufficient  to  justify  the  danger  which  is  in- 
curred. 

Excision  is  justifialile  and  should  be  done  in  all  cases  of  epithelioma 
situated  within  three  inches  of  the  anus  which  have  been  discovered 
before  infiltration  is  deep,  or  before  metastasis  has  occurred.  "When 
undertaken,  the  dissection  should  be  carried  on  well  away  from  the  dis- 
ease, in  the  perfectly  healthy  tissues.  It  is  performed  as  follows :  The 
patient  should  be  prepared  for  the  operation  by  being  placed  upon  liquid 
diet  for  one  week,  and  the  lower  bowel  should  be  thoroughly  cleansed 
by  repeated  injections  of  tepid  water.  A  good  light  should  l)e  secured, 
the  patient  placed  in  the  lithotomy  position,  and  the  parts  in  the  field 
of  operation  shaved.  The  rectum  should  be  well  packed  with  sponges 
to  prevent  the  escape  of  fluids  or  other  matter  from  the  bowel  into  the 
woimd.  The  number  of  sponges  shoiild  be  noted,  so  that  the  operator 
may  be  sure  that  none  are  left  in  after  the  excisiim  is  completed.  In 
order  to  secure  as  great  a  degree  of  continence  after  the  operation  as 
possible,  all  or  a  portion  of  the  external  sphincter  should  be  preserved. 
However,  if  the  disease  involves  this  muscle,  it  should  be  removed. 

An  elliptical  incision  is  fii-st  made  around  the  anus  along  tlie  junction 
of  the  skin  and  mucous  membrane  (or  wider  than  this  if  the  extent  of 
the  disease  demands  it),  and  the  dissection  earned  up  through  the  inner 
fibei's  of  the  external  sphincter,  the  posterior  insertion  of  which  should 
be  split  as  far  back  as  the  tip  of  the  coccyx,  in  order  to  give  more  room. 
When  the  disease  is  approached,  the  dissection  should  be  kept  well  out 
from  the  gut  in  the  healthy  tissues.  Within  the  first  inch  of  the  dissec- 
tion the  bleeding  points  may  be  readily  secured  by  the  forceps,  but, 


544  A  TEXT-BOOK  ON  SURGERY. 

beyond  tliis  limit,  tho  operation  will  ln'  luiicli  iiKne  rapidly  and  satis- 
factorily ])L'rf(>rmed  if  the  tissues  are  divided  (lirouylioiit  between  two 
forcex)s  and  catgut  ligatures  applied  at  once.  It  is  best  not  to  encroacli 
npon  the  vagina  or  urethra  and  bladder  any  more  than  is  essential  to  the 
thorough  removal  of  tlie  disease,  but  to  utilize  the  isehio-rectal  fossa  in 
securing  room  for  the  ileeper  dissection.  As  soon  as  the  lower  end  of 
the  rectum  is  freed,  the  wound  should  be  packed  temporarily  with  gauze, 
the  sponges  removed,  and  the  bowel  closed  by  tying  a  strong  silk  liga- 
ture around  it.  It  is  essential  to  the  complete  success  of  the  ojjeration 
that  the  gut  be  dissected  loose,  not  only  an  inch  above  the  upper  limit  of 
the  disease  where  it  is  nltimately  to  be  divided,  but  to  a  sufficient  extent 
beyond  tliis  point  to  permit  its  being  drawn  down  until  it  can  be  stitched 
to  the  nuirgiu  of  the  incision  in  the  integument  around  the  anus.  When 
this  is  accomplished  the  gut  should  be  drawn  down,  a  strong  silk  suture 
carried  through  the  integument  on  each  side  and  into  the  wall  of  the 
intestiue,  just  al>ove  the  line  of  section,  and  secured.  The  gut  slioidd 
now  be  cut  off  with  the  scissors,  and  other  sutures  inserted.  A  drain- 
age-tube should  be  placed  in  the  ischiorectal  fossa,  the  end  i)rojecting 
on  one  side  of  the  anus.  A  sublimate  dressing  should  be  applied,  leaving 
a  tube  in  the  bowel  for  the  escape  of  gas.  In  the  after-treatment  opium 
should  l)e  administered  to  prevent  a  movement  of  the  bowels  for  a  week 
or  ten  days. 

Polypus. — Three  distinct  forms  of  polypi  are  found  in  the  rectum, 
namely — the  villous,  mucous,  and  fibrous. 

The  lirst  of  these  is  the  more  important,  for,  while  essentially  benign 
in  the  earlier  stages  of  its  development,  it  not  infrequently,  as  a  result 
of  the  irritation  to  which  it  is  subjected,  becomes  malignant.  It  is  com- 
iwsed  of  new-formed  villi,  which  resemble  the  normal  villi  of  the  rectum. 
Tliey  are  very  vascular,  and  differ  from  the  mucous  or  fibrous  polypus 
not  only  in  their  minute  structure,  but  in  gross  appearances  and  the 
character  of  their  attachment  to  the  mucous  membrane.  While  these 
latter  are  pedunculated,  often  hanging  by  a  narrow  stem,  the  villous 
growth  has  a  broad  attachment  frequently  as  thick  as  the  tumor  is  long. 

The  mucous  or  soft,  and  the  fibrous  or  hard,  polypus  of  the  rectum 
does  not  diifer  in  any  essential  particular  from  that  already  described 
in  affections  of  the  nasal  cavities.  In  scmie  instances  the  deeper  portions 
of  tlie  tumor  undergo  cystic  degeneration,  forming  the  so-called  cystic 
polypus. 

Polypi  of  the  rectum  may  occur  at  any  period  of  life,  being  compara- 
tively frequent  in  childhood.  The  most  common  location  of  these  tumors 
is  on  the  posterior  wall  of  the  bowel,  just  above  the  internal  sphincter. 
The  pedunculated  variety  in  some  instances  protrude  through  the  anus, 
causing  violent  tenesmus.  When  not  removed  these  neoplasms  may 
break  down,  causing  ulcer  or  fissure  of  the  bowel,  severe  haemorrhage, 
or  by  their  weight  cause  prolapse  of  the  mucous  membrane. 

Tile  diagnosis  is  readily  made  by  inspection  or  digital  exploration, 
after  tlie  rectum  is  thoroughly  cleansed  by  an  enema.  The  treatment 
consists  in  removal  of  the  tumor  by  the  forceps,  scissors,  or  ligature. 


PROLAPSUS   OF  THE  RECTUM  AND  ANUS.  545 

Villous  polypus  may  be  safely  removed  by  transfixing  its  base  with  a 
double  silk  ligature,  tying  these,  and  allowing  the  mass  to  slough  away  ; 
or,  with  the  sphincter  fully  dilated,  the  tumor  maybe  removed  Ijy  the 
curette.  The  haemorrhage  is  not  severe,  and  may  be  arrested  by  packing 
with  gauze. 

The  pedunculated  tumors  may  be  twisted  off  with  the  forceps  or 
clipped  closely  with  the  curved  scissors.  The  stump  should  be  touched 
with  lunar  caustic  or  burned  with  nitric  acid  or  the  cautery. 

Neuralgia. — Pain,  neuralgic  in  character,  is  occasionally  felt  in  the 
rectum  or  about  the  anus.  In  some  instances  it  is  caused  by  displace- 
ment of  the  coccyx,  the  bone  in  the  abnormal  position  pressing  upon  the 
fifth  sacral  or  coccygeal  nerve,  or  directly  against  the  wall  of  the  bowel. 
The  diagnosis  is  readily  made  out  by  direct  examination.  The  only 
means  of  cure  is  by  removal  of  the  displaced  bone. 

The  operation  is  performed  as  follows :  The  patient  is  placed  upon 
the  side,  an  incision  is  made  in  the  median  line,  from  the  tip  of  the  coc- 
cyx to  about  one  inch  above  the  sacro- coccygeal  articulation.  The  tissues 
are  first  lifted  directly  fi'om  the  dorsal  aspect  of  the  bone,  and  then  the 
anterior  surface  is  exposed  by  beginning  at  the  tip  and  keeping  close 
to  the  smooth  face  of  the  coccyx.  There  is  no  danger  of  wounding  the 
bowel  if  this  precaution  is  taken.  When  the  dissection  is  completed, 
the  bone  should  be  divided  at  the  sacro-coccygeal  junction  with  the  cut- 
ting-forceps or  chisel. 

Idiopathic  neuralgia  of  the  rectum  and  anus  may  occur  as  in  other 
portions  of  the  body.  Spasm  of  the  sphincter  is  occasionally  due  to  this 
cause. 

Prolapsus  Recti. — Protrusion  of  the  rectum  may  be  complete  or  in- 
complete.  In  the  incomplete  variety  the  lining  membrane  of  the  bowel 
is  alone  protruded.  The  everted  portion  may  include  a  narrow  ring  of 
the  mucous  membrane  near  the  anus,  or  it  may  measure  an  inch  or  more 
in  widtli.  In  the  complete  prolapsus  more  or  less  of  the  entire  thick- 
ness of  the  wall  of  the  rectum  is  dragged  downward  and  everted.  The 
process  commences  usually  near  the  anus,  and  in  the  complete  form  the 
fascia  which  attaches  the  rectum  to  the  promontory  of  the  sacrum  is 
elongated,  and  the  peritonaium  dragged  down  toward  the  anal  aperture. 
In  the  pocket  thus  formed  a  looja  of  intestine  may  descend  and  become 
strangulated. 

Prolapsus  recti  may  occur  at  any  period  of  life,  although  usually  met 
with  in  children.  In  a  varying  degree  it  exists  as  a  com])lication  in  all 
cases  of  chronic  haemorrhoids.  It  is  chiefly  caused  by  frequent  and  pro- 
longed straining  at  stool.  A  predisposing  cause  in  adults  is  habitual 
constipation,  Avith  the  over-distention  of  the  bowel  which  is  the  result 
of  this  condition.  In  children,  it  is  thought  that  the  peculiar  shape  of 
the  sacrum,  the  curve  of  which  is  much  less  pronounced  than  in  adults, 
renders  this  class  of  i^atients  more  liable  to  prolapsus.  It  is  probable 
that  indiscretions  in  diet,  the  lack  of  restraint,  and  the  low,  squatting 
jiosture  too  often  permitted  in  children  in  the  act  of  defecation,  ai-e  more 

responsible  for  this  accident  than  the  straight  position  of  the  bowel. 
35 


546  A  TEXT-BOOK   ON   SURGERY. 

Diseases  of  the  bladder  and  ])ru.state,  uterus  and  ovaries,  pregnancy, 
or  the  presence  of  a  tumor,  are  also  to  be  considered  as  exciting  causes 
of  this  lesion.  Finally,  the  weak  and  infimi  are  more  liable  to  be 
affected  than  the  robust. 

When  prolapsus  occurs  it  is  accompanied  with  a  sense  of  distention, 
heaviness,  and  di-agging  down,  which  causes  great  pain  and  anxiety  to 
the  iiatient.  In  recent  cases  in  which  thei-e  is  only  an  eversion  of  the 
mucous  membrane,  this  will  be  seen  projecting  beyond  the  limit  of  the 
anus  on  one  or  both  sides,  or  in  severer  cases  including  its  entire  cir- 
cumference. The  prolapsed  fold  or  ring  is  of  a  reddish-purjtle  color, 
varying  with  the  degree  of  strangulation,  and  is  broken  at  intervals  by 
furrows  or  depressions  which,  in  the  main,  seem  to  radiate  from  the 
center  of  the  protrusion.  When  complicated  with  haemorrhoids,  tliese 
will  be  easily  recognized  by  their  shape  and  color,  giving  a  swollen  and 
nodulated  appearance,  which  could  not  exist  in  simple  eversion.  In 
differentiating  partial  from  complete  prolapsus,  the  chief  jioints  are  the 
thinness  of  the  prolapsed  ring  in  the  partial  form,  and  the  radiating 
du'ection  of  the  furrows.  In  complete  prolapse  the  mass  is  markedly 
thicker,  more  strangulated,  and  the  folds  of  mucous  membrane  are  more 
nearly  circular  in  arrangement. 

Treatment. — In  acute  prolapsus  the  immediate  indication  is  to  I'elieve 
the  strangulation  and  restore  the  prolapsed  portion  to  its  normal  i)osi- 
tion.  Tlie  removal  of  the  cause  or  causes  of  the  accident  is  next  in 
importance.  The  first  indication  is  met  by  placing  the  patient  ujion 
the  left  side,  with  the  pelvis  well  elevated,  the  shoulders  and  head  de- 
pressed, or  in  the  knee-shoulder  position,  in  either  of  which  the  return 
of  the  bowel  is  aided  by  gravity.  The  lingers  of  the  operator  and  the 
protruded  mass  should  now  be  well  lubricated,  and  steady  and  gentle 
jiressure  exercised  irpon  the  tumor  in  the  direction  of  the  ncn-mal  posi- 
tion of  the  bowel.  In  almost  all  cases  this  practice  will  succeed.  When, 
on  accotint  of  spasm  of  the  sphincter,  the  strangulation  is  so  great  that 
gangrene  is  threatened  and  reduction  impossible,  an  an;x^sthetic  should 
be  administered  and  forcible  dilatation  effected  by  the  thumbs  of  the 
operator,  after  which  the  mass  will  readily  return  within  the  anus.  Once 
reduced,  the  greatest  pains  must  be  observed  to  prevent  the  repetition 
of  the  accident.  Fecal  accumulation  and  straining  should  be  prevented 
by  the  injection  of  cold  water  when  there  is  a  need  or  desire  for  an 
evacuation,  and  by  the  use  of  the  bed-pan.  In  children  it  is  essential 
that  they  should  not  be  allowed  to  squat  upon  a  low  vessel,  or  j^lace 
themselves  in  a  constrained  position  at  stool.  The  position  assumed 
should  be  one  where  gravitation  will  not  carry  the  intestines  toward  the 
anus.  Lying  upon  the  side,  with  the  buttocks  slightly  projecting  over 
the  edge  of  the  bed  or  table,  or  defecating  in  the  knee-elbow  position, 
should  be  insisted  upon.  Any  condition  which  contributes  to  the  cause 
of  prolapse  must  be  removed  or  palliated.  When,  despite  all  conserva- 
tive methods,  the  prolapse  becomes  chronic,  growing  progressively  worse, 
operative  interference  becomes  imperative.  The  preparation  of  the  jm- 
tient  is  the  same  as  for  other  operations  about  the  rectum.     After  the 


HyEMORRIIOIDS.  547 

narcosis  is  complete,  the  patient  is  placed  in  the  lithotomy  position,  with 
the  pelvis  elevated  to  such  an  extent  that  the  intestines  will  gravitate 
toward  the  diaphragm,  the  mass  returned,  and  a  large  sponge  introduced 
well  U15  into  the  bowel.  The  sphincter  ani  and  rectum  should  now  be 
widely  dilated  with  the  speculum  until  the  walls  of  the  bowel  are  brought 
clearly  into  view.  The  Paquelin  cautery-knife,  heated  to  a  light-red 
color,  is  carried  into  the  bcjwel  as  high  as  the  limit  of  the  piolapsed 
portion,  and  drawn  straight  down  the  wall  of  the  gut  to  the  margins  of 
the  anus,  burning  its  way  through  the  mucous  membrane.  The  depth 
of  the  furrow  must  be  determined  by  the  extent  of  the  prolapse.  If 
the  entire  thickness  of  the  rectal  wall  is  involved,  as  in  complete  pro- 
lapsus, the  wound  should  extend  well  into  the  muscular  layer.  In  par- 
tial prolapse  it  will  suffice  to  go  down  to  the  muscle.  From  four  to  six 
incisions  should  be  made  at  equal  distances  from  each  other.  Partial 
divulsion  of  the  sphincter  should  be  made  before  or  after  the  operation, 
in  order  to  prevent  spasm  and  to  secure  rest.  A  complete  recovery  will 
follow  in  the  large  majority  of  cases.  If  the  Paquelin  cautery  can  not 
be  obtained,  strong  iron  wire,  or  rod-iron,  may  be  used  by  heating  in 
the  ordinary  furnace.  The  after-treatment  is  to  keep  the  jiatient  quiet 
with  mild  opium  narcosis,  and  after  live  or  six  days  to  move  the  bowels 
with  a  cold-water  enema,  keeping  the  patient  in  the  recumbent  posture. 
The  cure  is  effected  by  the  formation  of  inflammatory  adhesions  between 
the  mucous  membrane  and  muscle,  and  between  the  outer  wall  of  the 
rectum  and  the  peri-rectal  connective  tissues  and  fascise.  The  older 
operation  of  excising  a  V-shaped  piece  of  the  mucous  membrane  and 
afterward  uniting  the  edges  by  sutures,  is  bloody  and  troublesome,  and 
not  to  be  compared  to  the  procedure  above  given. 

In  chronic  prolapsus,  the  operation  is  the  same,  provided  that  reduc- 
tion can  be  effected.  The  incisions  with  the  cautery-knife  must  extend 
deeply,  as  above  indicated.  When  reduction  is  impossible,  owing  to  the 
inflammatory  thickening  of  the  protruded  mass,  there  is  no  alternative  but 
in  excision.  In  this  operation  the  integrity  of  the  sphincter  must  not  be 
impaired.  Preferably,  the  mass  should  be  cut  off  with  a  delicate  cautery- 
knife,  keeping  just  outside  the  sphincter,  which  is  usually  slightly  drawn 
out  with  the  gut.  The  line  of  incision  should  be  circular,  and,  by  allow- 
ing the  knife  to  burn  its  way  slowly,  all  danger  of  hferaorrhage  is  avoid- 
ed.    The  after-treatment  is  the  same  as  in  the  preceding  ojjeration. 

Another  method  is  to  insert  a  series  of  ligatures  of  strong  silk  around 
the  prola^jsed  mass  at  the  level  of  the  anus.  These  extend  through  both 
thicknesses  of  the  gut.  When  tied  tightly,  strangulation  of  the  jiortion 
beyond  the  ligatures  occurs,  and  this  should  be  cut  off  to  within  a  quar- 
ter of  an  inch  of  the  ligatures. 


*t)-' 


HEMORRHOIDS. 

Hsemorrhoids,  or  "piles,"  are  vascular  tumors  formed  beneath  the 
mucous  membrane  of  the  rectum  and  anus.  Tliey  are  divided  anatom- 
ically into  external  and  internal  h.emorrhoids.     Internal  luemoixhoids 


548  A  TEXT-BOOK   ON   SURGERY. 

are  agaia  divided  into  venous,  arterio-ve/ious,  and  capillanj  liajnior- 
rhoids. 

The  veins  which  are  involved  in  hifmorrlioids  belong  to  two  ])lexuse9, 
between  which,  ordinarily,  tliere  is  not  a  free  anastomosis.  Tiie  infeiior 
or  external  hjemorrlioidal  plexus  is  situated  in  the  last  portion  of  the 
rectum,  within  about  one  inch  of  the  anus,  and  the  blood  from  this  part 
returns  by  way  of  the  middle  and  inferior  hjrmonhoidal  veins  to  the 
iliacs,  and  thence  by  the  infeiior  cava  to  the  heart.  The  sujierior  or  in- 
ternal plexus  occupies  the  rectum  above  this  point,  and  from  this  por- 
tion the  lilood  returns  by  the  portal  system,  passing  thi-ough  the  liver. 

In  their  iucipiency,  external  lice morrii aids  are  simple  varicosities  of 
the  inferior  plexus.  Later,  as  a  residt  of  engorgement  and  repeated  in- 
flammation, the  walls  become  thickened  from  the  presence  of  newly 
formed  connective  tissue,  which,  in  the  process  of  contraction  peculiar 
to  this  product  of  inflammation,  often  causes  obliteration  of  the  vein 
within  the  tumor.  The  remains  of  these  tumors  are  seen  in  almost  all 
cases  of  chronic  external  haimoiThoids,  where  they  appear  as  tags  of 
thickened  skin  of  variable  size  and  shape,  collected  around  the  margin 
of  the  anus. 

Internal  JiamorrTiolds  of  recent  development  are  also  varicosities  of 
the  internal  or  portal  plexus,  but  when  of  long  duration  the  tumors 
very  frequently  contain  arterioles  of  considerable  size.  The  mucous 
membrane  of  the  deeper  portions  of  the  rectum  is  at  times  studded  with 
small,  raspberry-like  elevations,  which  bleed  profusely,  are  found  to 
contain  a  rich  network  of  capillaries,  and  fur  this  reason  are  termed 
capillary  Jicemorrholds. 

External  Hicmorrhoids — Acute  and  CTironic. — This  form  of  tumor, 
commonly  known  as  "dry  piles,"  is  of  frequent  occurrence.  Few  indi- 
viduals live  beyond  the  age  of  forty  without  being  aifected  with  this 
lesion.  The  chief  cause  is  habitual  constij^ation  and  the  over-distention 
of  the  lower  portion  of  the  rectum  in  the  act  of  defecation.  Prolonged 
straining  at  stool,  even  without  the  discharge  of  fecal  matter,  will  also 
aid  in  the  develcjpment  of  piles.  Gravitation  by  reason  of  the  erect 
posture  is  also  entitled  to  a  consideration  in  the  eetiology  of  hjemor- 
rhoids,  since  man  is  the  only  animal  thus  affected.  Pressure  upon  the 
iliac  veins  or  the  inferior  cava  by  the  gravid  uterus,  or  any  form  of 
tumor,  will  also  aid  in  producing  varicosities  of  the  hfemorrhoidal  veins 
as  well  as  in  those  of  the  lower  extremities. 

A  patient  who  is  suffering  from  an  acute  external  hsemoiThoidal  tu- 
mor will  usually  give  a  history  of  constipation  and  straining  at  stool, 
wath  an  unnatural  sense  of  fullness  and  heaviness  about  the  anus,  and 
of  consideralne  pain  while  the  evacuation  is  taking  place,  for  several 
days  before  the  protrusion  is  noticed.  Immediately  after  an  evacuation 
a  swelling  is  noticed  just  outside  of  the  anus  which  is  painful  to  the 
touch,  and  which  can  not  be  pushed  into  the  bowel.  Uj^on  inspection, 
a  recent  external  hjemorrhoidal  tumor  usually  ai)pears  tense  and  glis- 
tening on  the  surface,  and  red  or  reddish-blue  in  color.  It  is  partly 
within  and  partly  outside  of  the  anus.     There  may  be  a  single  swell- 


IliEMORRIIomS.  549 

ing,  wMch  is  spherical  in  shape,  or  it  may  be  crescsntic,  occupying  half 
of  the  anal  margin.  If  not  observed  until  after  several  days  have 
elapsed,  and  v.hen  the  tension  or  partial  strangulation  has  not  been  re- 
lieved, ulceration  may  have  occurred,  with  intlammation  and  induration 
of  the  tissues  near  the  base  of  the  tumor.  In  other  instances  vv'hich  do 
not  come  under  the  observation  of  a  physician,  the  patient  goes  to  bed, 
pushes  the  tumor  within  the  anus,  the  symptoms  disapj^ear  within  a  day 
or  two,  to  recur  again  and  again  imder  the  same  conditions. 

Chronic  external  InemorrJioids  differ  from  the  acute  form  just  de- 
scribed in  the  following  particulars  :  They  are  bro\\Ti  or  bluish  in  color, 
are  not  tense  nor  painful,  are  loose  and  flabby,  and  have  a  thickened, 
leathery  feel  when  pinched  between  the  fingers. 

Treatment. — The  treatment  may  be  palliative  or  curative.  If  the 
palliative  treatment  is  determined  upon,  the  immediate  indication  is  to 
relieve  the  tension  in  the  tumor  by  returning  it  within  the  anus.  The 
patient  should  be  placed  in  the  left  lateral  or  knee-shoulder  position, 
the  protruded  portion  and  fingers  of  the  operator  thoroughly  lubricated, 
?ind  reduction  effected  by  well-directed  pressure,  combined  with  slight 
dilatation  of  the  sphincter.  If  the  tumor  is  so  large  that  it  can  not  be 
reduced,  relief  may  be  obtained  by  the  local  application  of  the  ice-bag, 
or  cold  water.  The  majority  of  cases  will  be  relieved  temporarily  by 
this  treatment,  and  a  certain  proportion  may  not  suffer  a  relapse,  but 
the  rule  is  for  the  tumor  to  recur  from  time  to  time  until  it  is  cured 
finally  by  an  operation. 

In  operating  for  the  cure  of  external  piles,  the  ligature  is  rarely  de- 
manded. If  the  tumor  is  recent  and  is  inflamed,  immediate  relief  may 
be  obtained  by  incising  it.  This  procedure  may  be  rendered  painless 
by  the  following  method :  The  smallest  hypodermic  needle  is  attached 
to  the  syringe,  containing  about  v\  xv  of  a  4-per-cent  solution  of  cocaine 
hydrochlorate.  The  needle  is  introduced  into  one  side  of  the  tumor  at 
its  base  to  the  depth  of  about  one  eighth  of  an  inch,  and  three  or  four 
minims  of  the  solution  forced  out ;  a  minute  later  it  is  carried  farther, 
and  the  manoeuvre  repeated  until  the  needle  has  completely  transfixed 
the  mass,  and  all  the  fluid  injected.  Within  five  minutes  the  anfesthe- 
sia  is  usually  so  complete  that  the  tumor  can  be  laid  open  with  the 
bistoury  without  pain.  The  bleeding  is  insignificant,  and  is  easily  ar- 
rested by  packing  a  tuft  of  borated  cotton  or  lint  into  the  wound.  No 
after-treatment  is  required.  The  wound  heals  after  five  or  six  days  and 
the  pile  is  cured. 

Old  external  piles  may  be  removed  by  grasping  the  tumor  with  a  pair 
of  mouse-tooth  forceps  and  clipping  it  off  near  its  base  with  a  jiair  of 
scissors  curved  on  the  fiat.     Local  anaesthesia  should  also  be  employed. 

Internal  HcemorrTioids. — Constipation,  over-distention  of  the  rectum, 
and  prolonged  straining  at  stool  must  also  be  considered  as  among  the 
principal  causes  of  internal  as  well  as  external  piles.  In  addition  to 
these,  any  disease  of  the  liver  which  causes  a  retardation  of  the  return 
of  blood  through  the  portal  circulation  will  aid  in  producing  internal 
htemorrhoids. 


550  A  TEXT-BOOK   ON    SURGERY. 

Pressure  upon  the  portal  vein,  or  upon  tlie  inferior  mesenteric  veiii, 
whether  due  to  an  overloaded  condition  of  the  alimentary  canal,  or  a 
tumor,  will  produce  the  same  effect. 

Si/irij)t()inx. — Internal  piles,  as  a  rule,  cause  little  or  no  pain  or  an- 
noyance until  they  are  sufficiently  developed  to  be  caught  in  the  grip 
of  the  sphincter,  or  are  protruded  througli  tlie  anus.  Previous  to  their 
descent,  however,  a  variable  amount  of  bleeding  has  usually  occurred, 
often  enough  to  attract  the  attention  and  excite  the  alarm  of  the  patient. 
This  is  especially  true  of  the  arterio-venous  and  capillary  tumor,  al- 
though the  venous  tumor  not  infrequently  gives  rise  to  considerable 
haemorrhage. 

Upon  digital  examination  the  presence  of  the  haemorrhoids  may  be 
easily  recognized,  and  ocular  deuKmstration  may  be  made  by  the  care- 
ful dilatation  of  tlie  sphincter  with  the  Sims  rectal  speculum.  If  a  free 
enema  of  wann  water  be  administered,  the  tumors  will  usually  ])rotrude 
with  the  discharge  of  the  water  if  the  patient  is  placed  in  the  sipiatting 
posture,  and  is  dii-ected  to  make  a  strong  expulsive  effort. 

Treatment. — Venous  and  arterio-venous  internal  haemorrhoids  may 
be  cured  by  one  of  three  methods — the  ligature,  the  clamp,  and  the  in- 
jection of  carbolic  acid  ;  the  capillary  variety  by  the  mild  application  of 
the  cautery  or  nitric  acid. 

Of  the  first  methods  mentioned  there  is  little  room  for  choice  between 
the  ligature  and  the  clamp,  and  both  of  these  are  preferable  to  the  car- 
bolic-acid injection.  Operation  by  the  ligature  is  deservedly  the  more 
popular,  for  the  reason  that  it  is  not  only  simple,  radical,  and  success- 
ful, l)ut  does  not  require  any  sjiecial  or  costly  apparatus  for  its  perfomi- 
ance.  The  objections  to  the  operation  with  carbolic  acid  are,  that  it 
does  not  always  succeed,  it  requires  a  long  time — several  weeks,  and  at 
times  months — in  effecting  a  cure,  peri-proctitis  and  abscess  of  the  ischio- 
rectal fossa  may  ensue,  and  hepatic  embolism,  witli  abscess,  is,  however 
remote,  a  possibility.  Not  unfrequently  ulcer  of  the  bowel  results, 
which  of  itself  requires  to  be  cured.  In  its  favor  it  may  be  said  that 
the  treatment  can  be  carried  on  without  ether  narcosis,  in  almost  aU  cases 
without  going  to  bed,  and  is  not,  as  a  rule,  accompanied  l)y  great  pain. 
Since  the  operati(Ui  by  the  ligature  is  almost  universall}'  recognized  by 
surgeons  as  the  safer  and  more  scientific  procedure,  it  should  be  recom- 
mended. If  the  patient  for  any  reason  can  not  submit  to  it,  the  method 
of  injection  may  be  undertaken  if,  after  a  full  explanation  of  the  differ- 
ent methods,  the  opei-ator  is  relieved  of  all  responsibility. 

Operation  hy  the  Ligature. — Tlie  preparation  of  the  pfitient  is  the 
same  as  in  other  operations  about  the  rectum.  When  fully  anaesthe- 
tized, the  lithotomy  position  should  be  preferred,  or,  if  help  is  scarce,  or 
the  convenience  of  the  operator  is  better  suited,  the  patient  may  be 
placed  upon  the  left  side,  ^vith  the  left  arm  behind  the  body  and  the 
thighs  and  legs  flexed. 

The  first  step  is  the  dilatation  of  the  sphincter,  which  is  accomplished 
by  introducing  the  thumbs  and  stretching  the  muscle  toward  the  tuber- 
osities of  the  ischia  until  relaxation  is  complete.     A  soft  sponge  is  car- 


HEMORRHOIDS.  551 

ried  into  the  rectum  above  the  piles  in  order  to  prevent  the  descent  of 
fecal  matter.  The  hsemorrhoidal  tumors  are  now  carefully  examined 
and  drawn  downward.  If  the  tumors  are  of  considerable  thickness 
through  their  bases,  it  is  best  to  use  a  double  ligature.  In  narrow,  pe- 
dunculated haemorrhoids  a  single  thread  will  suffice.  The  operator,  hold- 
ing the  tumor  steady  and  tense  by  means  of  a  forceps  or  hook,  with  a 
knife  or  scissors  divides  the  mucous  membrane  all  ai-ound  the  base  of 
the  tumor,  going  well  down  to  the  submucous  layer  and  making  a  fur- 
row in  which  the  ligaturs  is  to  rest  as  it  constricts  the  tumor.  This 
incision  not  only  hastens  the  separation  of  the  mass,  but  diminishes 
greatly  the  pain  which  would  otherwise  be  felt  if  the  end-organs  of  the 
sensory  nerves  distributed  in  the  mucous  membrane  were  caught  in  the 
grasp  of  the  ligature.  When  an  internal  haemorrhoidal  tumor  is  com- 
plicated by  an  external  pile — that  is,  when  the  tumor  is  mixed — the  in- 
tegument around  the  tumor  should  also  be  incised.  The  ligatures  should 
be  of  the  very  best  silk,  so  lai-ge  and  strong  that  they  can  not  be  broken 
in  tying.  If  they  are  well  waxed,  they  will  be  less  apt  to  slip  when  the 
knot  is  being  made.  If  a  single  thread  is  to  be  employed,  it  may  be 
thrown  around  the  pedicle  of  the  tumor  and  tied.  It  is  almost  always 
advisable  to  use  the  double  ligature.  This  may  be  carried  through  the 
base  of  the  hsemorrhoid  by  means  of  a  good-sized  half-curved  needle, 
or  Peaslee's  needle  may  be  used.  If  the  tumor  is  not  complicated  with 
an  external  hsemorrhoid — that  is,  if  its  base  is  well  within  the  anus — it 
may  be  transfixed  directly  through  its  base,  the  thread  divided  at  the 
eye  of  the  needle,  and  this  instrument  removed.  Tlie  two  ligatures  are 
now  separately  identified — one  for  the  lower  and  one  for  the  upper  half 
of  the  mass — and  are  then  crossed  by  carrying  the  lower  end  of  one  side 
once  over  the  upper  and  back  to  its  place.  By  this  manoeuvre  the  two 
loops  are  interlocked,  and,  when  tied,  all  the  tissues  in  the  grasp  of 
both  threads  are  crowded  to  the  center. 

As  the  ligatures  are  being  tied,  care  must  be  taken  to  see  that  the 
threads  fall  into  the  track  of  the  incision  already  made  through  the 
mucous  membrane  (or  integument).  If  the  threads  have  been  waxed, 
the  "reef-knot"  (Fig.  110)  should  be  preferred,  since  a  more  complete 
strangulation  can  be  secured  with  less  strain  on  the  silk  than  when  the 
"friction-knot"  (Fig.  112)  is  employed.  When  wax  is  not  used,  this 
last  knot  is  preferable,  for  the  reason  that  it  is  less  apt  to  slip.  The 
force  employed  should  be  sufficient  to  arrest  the  circulation  in  the  tumor, 
which,  when  this  is  done,  immediately  becomes  purple  and  very  tense. 
When  all  the  tumors  have  been  deligated,  they  should  be  clipped  off 
with  the  curved  scissors  about  a  quarter  of  an  inch  from  the  ligatures, 
and  the  threads  cut  short.  The  sponge  should  next  be  removed,  a  gauze 
dressing  or  pad  laid  over  the  anal  region,  and  a  T-bandage  api")lied.  It 
is  usually  advisable  to  administer  morphia  hypodermically  at  the  close 
of  the  operation,  and  to  continue  this  for  two  or  three  days.  The  bowels 
may  be  moved  on  the  fourth  day.  The  dressing  should  be  changed  as 
often  as  cleanliness  requires.  The  ligatures  come  away  between  the 
sixth  and  tenth  days.     In  this,  as  in  all  operations  about  the  rectum,  re- 


552  A  TEXT-BOOK  ON  SURGERY. 

tention  of  urine  is  apt  to  follow  for  a  day  or  two,  necessitating  the  nse 
of  the  cathetei".  Peimanent  incontinence  of  fseces  rarely  results  from 
this  procedure.  It  is  more  apt  to  occur  in  females,  and  this  danger  should 
be  avoided  by  a  limited  divulsiou  of  the  sphincter. 

When  the  base  of  a  hjemon-hoidal  tumor  is  more  than  one  inch  in  its 
long  axis,  it  is  best  to  insert  two  sets  of  ligatures  rather  tlian  to  include 
too  much  tissue  in  the  grasp  of  a  single  tliread.  Half-way  Ijetween  the 
two  sets  of  threads  a  perpendicular  incision  should  be  made  through  to 
the  base  of  the  tumor,  so  that  tiie  central  ligatures  may  l)e  sunk  to  the 
sLime  level  as  the  others.  If  this  precaution  is  not  taken,  an  uneven 
surface  will  be  left  when  the  ligatures  come  away. 

The  operation  with  the  damp  and  cautery  is  perfoi-med  as  follows  : 
The  tumor  is  drawn  out  and  grasped  at  its  base  between  the  jaws  of 
the  clamp  (Fig.  562),  and  the  blades  closed  by  tightening  the  screw  in 


Flo.  562.— Smith'8  htemorrhoid.il  clamp  (ivory-plated), 

the  handles  nntil  the  hfemorrhoid  is  strangulated.  With  the  scissors 
the  mass  is  cut  away  about  one  fourth  of  an  inch  external  to  the  clamp., 
and  the  cut  surface  thoroughly  cauterized  with  the  Paquelin  or  the  act- 
ual cautery.  The  ivory  plates  upon  the  jaws  of  the  clamp  protect  the 
mucous  membrane  of  the  bowel  from  lieing  burned.  When  this  is  done, 
the  blades  should  be  .slowly  separated,  and,  if  any  oozing  is  seen,  the 
bleeding  point  should  be  again  touched  with  the  cautery.  The  after- 
treatment  is  the  same  as  for  the  preceding  operation. 

Injection  with  Carbolic  Acid. — The  htemorrhoid  to  be  operated  upon 
should  be  exposed  with  the  speculum  or  drawn  well  out  with  the  finger.s. 
If  it  is  a  long  pedunculated  tumor,  the  needle  should  be  introduced 
from  the  point  to  near  its  base.  If  it  is  round  or  oval  in  shape,  the 
needle  should  pass  through  the  longer  diameter  of  the  mass  near  the 
level  of  tlie  mucous  membrane  of  the  Iwwel.  The  mucous  membrane 
and  integument  should  be  well  covered  with  vaseline  to  prevent  excoria- 
tion from  the  acid  which  may  leak  from  the  syringe  or  ooze  out  of  the 
tumor. 

The  ordinary  hypodermic  syringe  will  answer  every  purpose  if  one  or 
two  extra  long  and  fine  needles  are  secured.  In  Fig.  563  is  shown  an 
apparatus  especially  designed  for  this  operation. 

From  ten  to  twenty  minims  of  a  4-i)er-cent  cocaine  solution  (the  quan- 
tity being  determined  by  the  size  of  the  tumor)  are  first  thrown  in,  and 
the  instrument  unscrewed  from  the  needle,  leaving  this  sticking  in  the 
tumor.  The  carbolic-acid  solution  is  now  drawn  into  the  syringe,  and 
t his  is  again  screwed  on  to  the  needle.     After  fiom  one  to  three  minutes 


ILE3I0RRH0IDS. 


553 


the  aiiffistbesia  will  be  complete,  and  the  solution  should  be  forced  slowly 
into  the  tumor,  being  distributed  in  the  line  in  which  the  cocaine  was 
injected.  It  is  advisable  to  operate  upon  a  single  hfemorrhoid  at  each 
operation.  The  strength  of  the  solution  and  the  quantity  to  be  em- 
ployed will  be  determined  by  the  size  and  condition  of  the  tumor.     If  a 


Fig.  563. — Kelsey's  hicinorrho'Klal  s}•rin^'e. 


rapid  sloughing  of  the  mass  is  desired,  this  result  may  be  secured  by 
using  a  solution  of  equal  parts  glycerin  and  carbolic  acid,  and  from  five 
to  twenty  minims  should  be  introduced  unless  the  htcmorrhoid  ia  un- 
usually large.  After  injecting  a  solution  of  this  strength  the  tumor  be- 
comes hard,  and  changes  to  a  blue  or  bluii^h-gray  color.  In  from  twenty- 
four  to  forty-eight  hours  the  mass  sloughs  away,  and  by  the  fourth  or 
fifth  day  has  disappeared,  leaving  only  a  small  ulcer  in  the  mucous  mem-, 
brane  corresponding  to  the  base  of  the  hajmorrhoid.  If  a  10-per-cent 
solution  is  employed,  sloughing  rarely  occurs,  and  a  much  greater  quan- 
tity— from  twenty  to  thirty  minims — can  be  injected.  A  mild  degree  of 
'inflammation  is  established,  followed  within  a  few  days  by  a  diminution 
in  the  size  of  the  tumor,  which,  in  a  certain  proportion  of  cases,  grad- 
ually undergoes  atrophy  and  entirely  disai)pears.  The  degree  of  pain 
following  the  injection  of  the  stronger  solution,  after  the  temporary 
anjesthesia  secured  by  the  cocaine  has  passed  off,  varies  with  different 
individiuils.  In  some  of  my  cases  it  was  so  insignificant  that  the  jjatients 
went  immediately  about  their  vocations.  In  others  the  same  solution 
caused  great  annoyance  and  considerable,  though  never  alarming,  inflam- 
mation. The  milder  solutions  are  also  painful  at  times,  though  in  a  less 
degree.  In  choosing  between  the  weak  and  strong  solutions  just  given, 
the  operator  must  be  guided  chiefly  by  the  time  in  which  it  is  desired 
to  effect  a  cure.  If  expedition  is  demanded,  the  strong  injections 
should  be  employed ;  if  not,  the  weak  solution  is  preferable  to  begin 
with,  and,  if  necessary,  this  may  be  increased  in  strength  at  a  subse- 
quent operation. 


554  A  TEXT-BOOK  ON  SURGERY. 

In  capillary  Jicemorrhoids  the  chief  symptom  is  haemorrhage.  The 
bleeding  occurs  with  and  after  each  stool,  or  may  follow  violent  exercise 
or  straining.  If  the  finger  is  carried  into  the  bowel,  no  tumors  are  felt, 
and  there  is  usually  no  tenesmus.  If  the  speculum  is  employed,  the 
mucous  membrane  will  be  seen  to  be  studded  with  bleeding  points  or 
rufts  projecting  a  slight  distance  from  the  normal  level  of  tlie  lining 
membrane  of  tlie  rectum.  They  are  red,  not  unlike  small  laspberries 
in  appearance,  and  bleed  profusely  at  the  slightest  provocation.  They 
are  really  new  formations  or  chronic  granulation-tissue,  lich  in  capillary 
loops. 

The  treatment  consists  in  dilatation  of  the  anus  and  rectum  with  the 
speculum,  and  in  touching  the  bleeding  points  with  the  Paquelin  can 
tery  until  all  ])leediug  ceases.     If  the  cautery  is  not  at  hand,  pure  nitric 
acid  should  be  applied. 


CHAPTER  XIX. 

GEXITO-URIXARY   ORGANS. 

Kidneys. — Certain  diseased  conditions  of  the  kidneys,  resulting 
chiefly  from  traumatism,  but  in  some  instances  idif)pathic  in  origin, 
demand  a  careful  consideration,  and  at  times  active  interference,  at  the 
hands  of  the  surgeon. 

Wounds. — Solutions  of  continuity  in  these  organs,  either  as  a  result 
of  concussion  or  from  the  penetration  of  a  foreign  body,  are  among  the 
most  dangerous  visceral  lesions.  Rupture  of  the  kidney  occurs  not  only 
from  violence  applied  immediately  over  the  anatomical  seat  of  this  organ, 
but  indirectly,  as  from  a  fall  on  the  head  or  feet.  The  conditions  which 
result  are  practically  identical,  whether  there  is  a  penetrating  wound  or 
not.  Hsemorrhage  is  immediate,  and  is  jiroportionate  to  the  extent  of 
kidney  involved  and  to  the  vascularity  of  the  part  injured.  Shock  is 
usually  well  marked.  Vomiting  is  present,  -nith  pallor,  cold  perspira- 
tion, rapid  and  weak  pulse.  Pain,  if  severe,  is  felt  in  the  region  of  the 
organ,  and  is  transmitted  in  the  direction  of  the  ureters,  down  the  leg, 
and  into  the  testicle  of  the  injured  side  in  the  male,  which  organ  is  usu- 
ally drawn  up  toward  the  external  ring.  Extravasation  of  urine  takes 
place,  and,  when  the  capsule  is  torn,  finds  its  way  into  the  loose  areolar 
tissue  of  the  retroperitoneal  space.  Hremorrhage  occurs  in  the  same  way, 
as  well  as  into  the  uriniferous  tubules  and  pelvis  of  the  kidney.  The 
organ  may  be  displaced  by  concussion,  usually  traveling  downward  and 
toward  the  median  line. 

The  s>/mj)toms,  although  varying  with  the  extent  of  the  lesion,  are 
usually  those  of  profound  shock.  Pain,  not  only  local,  but  extending 
in  the  direction  just  described,  together  with  the  presence  of  bloody 
urine,  in  a  patient  who  has  received  a  wound  in  the  lumbar  region,  or  a 
severe  concussion,  and  who  has  no  bladder  or  urethral  disease  to  account 
for  ha^maturia,  are  symptoms  which  point  quite  clearly  to  the  natiire  of 
the  injury.  Partial  suppression  of  urine  is  not  uncommon.  A  marked 
elevation  of  temperature  usually  follows  the  reaction  from  shock.  The 
febi'ile  movement  is  chiefly  due  to  the  inflammation  which  follows  the 
escape  of  urine  into  the  retroperitoneal  space.  With  the  advent  of 
pus-formation,  local  tenderness  is  increased,  the  area  of  inflammation 
spreads,  the  more  superficial  structures  become  tense,  the  integument  is 
reddened,  and  rigors  or  chills  occur,  followed  by  exacei'bations  of  tem- 
perature. 


t> 


556  A  TEXT-BOOK   ON   SURGERY. 

The  prognosis  is  imfavorable,  but  must  chiefly  depend  \\\\^-\\  the  ex- 
tent of  the  injury,  as  determined  by  the  earlier  symptoms. 

The  treatment  may  be  radical  or  conserpative.  Immediate  operation 
witliin  the  period  of  shock  is  scarcely  to  be  thought  of.  If  the  symi>tonis 
of  hsomorrhage  are  alarming,  deligation  of  the  extremities  should  be 
practiced,  and,  if  syncope  is  still  threatened,  the  intra-venons  injection 
of  a  saline  solution  should  l)e  perfoinied.  Direct  operative  interference, 
by  cutting  down  upon  the  wounded  organ,  will  be  rarely  called  for. 

"With  the  earliest  symi)tom  of  abscess  an  exploratoiy  incision  should 
be  made.  It  is  advisable  U>  insert  the  aspirator-needle  at  the  points  of 
greatest  tenderness  and  induration,  and,  if  pus  is  discovered,  the  incision 
should  be  made  along  the  needle  as  a  guide.  If  ])us  can  not  lie  obtained 
by  using  the  aspirator,  the  incision  is  still  indicated  if  the  symptoms  of 
sepsis  above  given  are  present.  The  organ  may  be  readily  reached  by 
cutting  ])ai'allel  with,  and  about  three  inches  and  a  half  external  to,  the 
spines  of  the  lumbar  vertebne.  Tiie  kidney  is  located  just  in  front  of 
the  outer  border  of  the  quadratus  lumborum  muscle,  its  lower  extremity 
reaching  down  to  the  level  of  the  umbilicus. 

If  an  abscess  is  found,  it  should  be  irrigated  with  l-to-5UUL)-sublimate 
solution,  and  free  drainage  established. 

The  kidney  is  often  the  seat  of  morbid  changes,  which  occur  partly 
from  internal  violence  and  partly  from  idiopathic  causes,  which  may  at 
times  justify  the  surgical  invasion  of  this  organ.  Pyelitis,  pyonephrosis, 
calculus,  hydronephrosis,  and  certain  new  formations,  as  cysts,  carci- 
noma, sarcoma,  rhabdomyoma,  adenoma,  angioma,  tuberculosis,  and 
giimnia,  are  among  the  ciiief  diseases  of  a  surgical  nature. 

Pyelitis,  or  inflammation  of  the  pelvis  of  the  kidney,  may  be  caused 
by  the  irritating  effects  of  calculi  in  the  calices  or  pelvis  of  this  organ, 
which  do  not  escape  readily  into  and  through  the  ureter;  to  over-disten- 
tion,  resulting  from  urethral,  vesical,  or  ureteral  obstruction,  or  by  exten- 
sion of  an  inflammatory  process  fi'om  below  u])ward  {urethritis,  ei/stitis, 
ureteritis).  It  is  less  frequently  caused  by  direct  violence  from  without, 
or  may  be  part  of  an  idiopathic  perinephritis.  It  is  readily  understood 
how  a  stricture  of  the  urethra,  enlarged  jirostate,  or  an  obstructed  ureter 
would  force  the  urine  back  upon  the  kidney,  causing,  in  severe  and 
chronic  cases,  destruction  of  this  organ,  and  a  pyelitis  before  this  could 
occur.  In  like  manner,  the  intlaniniation  in  a  urethritis  or  cystitis  may 
travel  along  the  ureter  until  the  pelvis  of  the  kidney  is  involved. 

The  diagnosis  of  pyelitis  can  not  be  so  readily  made  out  by  the  symp- 
toms referable  to  the  inflammaticm  in  the  pelvis  proper,  as  by  a  study  of 
the  conditions  which  precede  it.  Pain,  which  is  present  in  this  disease, 
is  present  in  a  variety  of  kidney  lesions,  and,  as  in  neuralgia  of  this  organ 
(nephralgia),  it  is  met  with  when  no  symptoms  of  inflammation  exist. 
If,  after  an  attack  of  renal  colic,  pain  of  a  more  constant  and  less  excru- 
ciating character  is  felt,  deep  in  the  lumbar  region,  ])eing  on  one  side 
only,  and  on  that  side  upon  which  the  colic  occurred,  and  if  pus  is  pres- 
ent in  the  urine  where  no  cystitis  or  urethritis  exists,  ]iyelitis  should  be 
strongly  suspected.     Persisting  pain  in  this  region,  in  a  patient  sufi'ering 


GENITO-URINARY   ORGANS.  557 

from  obstruction  in  the  urinary  track,  beyond  the  pelvis  of  the  kidney, 
is  also  strong  evidence  in  favor  of  pyelitis,  notwithstanding  that  the  piis 
present  is  known  to  come  from  other  sources.  Added  to  the  above,  the 
febrile  movement,  and  rigors  of  the  inflammatory  process,  the  frequent 
micturition,  tlie  exaggeration  of  pain  upon  pointed  and  deep  pressure, 
and,  in  the  later  stages,  the  presence  of  a  tumor,  caused  by  the  dilated 
organ,  and  the  diagnosis  of  i)yelitis  may  be  determined. 

In  cases  of  pyelitis  with  complete  obstruction,  pus  is  retained,  and, 
together  with  the  urine  excreted  by  the  tubules  not  yet  desti'oyed,  dis- 
tends the  pelvis,  together  with  the  kidney,  causing  a  hydro-pyo-nephro- 
sis,  ultimately  opening  into  the  peritonaeum,  jjleura,  or  retroperitoneal 
space,  or  it  may  open  through  the  integument  in  the  lumbar  region,  or 
near  Poupart's  ligament. 

Treatment. — This  must  be  directed  to  the  relief  of  pain,  to  the  removal 
of  the  cause  of  the  disease,  and  to  the  maintenance  of  the  patient's  powers 
of  resistance  by  judicious  feeding.  The  relief  of  pain  is  obtained  by  the 
employment  of  anodynes  and  by  counter-irritation,  as  by  sinapisms,  hot 
cloths,  and  cups  to  the  lumbar  region.  When  the  disease  is  obstinate, 
and  the  destruction  of  the  kidney  is  evident,  incision  should  be  made,  and 
free  drainage  secured,  or,  if  the  patient's  condition  wiU  justify  a  more 
formidable  procedure,  the  diseased  organ  should  be  removed. 

Hi/droHepfirosis  is  both  a  congenital  and  an  acquired  lesion.  In  the 
congenital  form  the  arrest  of  development  may  be  in  the  ureter  or  urethra, 
mth  partial  or  complete  occlusion  of  one  or  the  other  of  these  organs. 
The  urine,  being  unable  to  escape,  accumulates  and  distends  the  pelvis 
and  calices,  causing  destruction  of  the  tubules  and  Malpighian  tufts,  and 
terminating,  if  the  obsti'uction  is  sufficiently  prolonged,  in  a  cyst,  the 
wall  of  which  is  composed  of  the  pelvis  and  capsule  of  the  kidney.  As 
stated  above,  obstruction  of  the  urethra  usually  causes  inflammation  of 
the  pelvis,  the  result  being  not  a  simple  hydronephrosis,  but  a  hydro- 
pyo-nephrosis.  Simple  hydronephi-o.sis  occurs  in  rare  cases,  when  the 
obstruction  comes  on  gradually.  In  congenital  occlusion  the  distention 
of  the  pelvis,  the  atrophy  of  the  kidney,  and  the  development  of  a  large 
cyst  may  occur  without  inflammation.  The  character  of  the  obstruction 
will  vary.  Calculus  in  the  ureter,  or  stricture  residting  from  the  inflam- 
mation caused  by  the  descent  of  a  stone  to  the  bladder,  pressure  by  a 
neoplasm  or  another  organ,  and  all  lesions  of  the  bladder  and  urethra 
which  retard  or  aiTest  the  flow  of  urine,  may  produce  this  condition. 
At  times  the  tumor  is  so  small  that  it  may  escape  observation,  or  it 
may  almost  fill  the  abdominal  cavity. 

The  diagnosis  is  rarely  made  unless  the  cyst  is  suflSciently  large  to 
attract  attention.  The  presence  of  a  fluctuating  tumor  in  the  lumbar 
region  will  serve  to  suggest  hydronephrosis,  and  the  exploration  of  the 
cyst  with  a  very  fine  needle  will  exhaust,  by  aspiration,  a  fluid  which, 
under  the  microscope,  will  demonstrate  the  exact  nature  of  the  tumor. 
In  those  cases  where  the  obstruction  is  not  permanent,  but  recurs  at 
intervals,  the  disappearance  of  the  swelling,  with  the  discharge  of  an 
exti-aordinary  quantity  of  urine,  may  be  considered  almost  a  positive 


558  A  TEXT-BOOK  ON  SURGERY. 

symptom  of  this  condition.  When  tlie  cause  is  vesical  or  iiretliral,  both 
kidneys  will  be  affected.  Ursemic  symptoms  may  occur,  and  are  present 
in  the  latter  stages,  when  tlie  destruction  of  the  tubules  is  general.  If  tlie 
obstruction  is  gradual,  the  tolerance  of  unemia  is  at  times  great,  and 
when  only  a  single  kidney  is  affected,  especially  if  the  unilateral  occlu- 
sion is  not  sudden,  the  other  organ  will,  in  most  cases,  assume  a  functional 
activity  sufficient  for  the  work  of  both  kidneys. 

Hydrone]ilirosis  may  be  mistaken  for  hydatid  cysts  of  this  organ, 
for  ovarian  cysts,  cyst  of  the  pancreas  and  spleen,  or  for  abdominal 
dropsy.  In  alidominal  dropsy  the  fluid  gravitates  to  the  pelvis  and 
changes  with  the  diftVrent  positions  assumed.  Liver-disease  almost 
always  precedes  ascites.  Cysts  of  the  spleen  and  pancreas  are  rare, 
and  the  early  history  of  their  development  will  point  to  an  origin  away 
from  the  kidney.  In  hydatid  cysts  of  the  kidney  the  only  jiositive 
differentiation  is  in  the  recognition  of  the  hydatid  vesicles  in  the 
urine. 

Treatment. — In  mild  cases,  whether  the  disease  is  double  or  single, 
operative  interference  is  not  demanded.  In  stricture  of  the  urethra  or 
enlarged  prostate,  the  removal  of  the  obstruction  is  imperative.  Symp- 
toms of  ursemia  call  for  the  warm  bath  and  free  perspiration  in  the  effort 
to  eliminate  by  the  skin  the  necessary  quantity  of  urea.  To  this,  mild 
purgation  may  be  added.  "When  the  cyst  is  large  enough  to  interfere 
with  the  comfort  or  to  threaten  the  life  of  the  patient,  it  should  be 
aspirated  or  cut  down  npon  and  drained  by  incision,  or  completely  re- 
moved. In  introducing  the  aspirator-needle,  the  most  prominent  jiart 
of  the  proti'usion  near  the  last  rib  should  be  punctured.  If  the  con- 
dition of  the  patient  will  permit,  preference  should  be  given  to  incision 
and  free  drainage  of  the  cyst.  If  the  cyst-wall  has  not  adhered  fii-mly 
to  the  surrounding  tissues,  the  dissection  should  be  carried  down  to  the 
cyst  and  the  wound  jiacked  with  sublimate  gauze  for  a  day  or  two  iintil 
adhesions  have  taken  place,  after  which  the  contents  may  be  evacuated. 

Renal  Calculus. — Stone  in  the  kidney  may  be  formed  by  an  aggre- 
gation of  iirinary  crystals  in  the  tubules,  calices,  or  j^elvis  of  this  oi'gan. 
To  the  composition  of  these  bodies  epitlielia,  mucous  and  other  organic 
substances  contribute.  Although  chiefly  composed  of  uric  acid  in  va- 
rious combinations,  and  oxalic  acid  in  combination  with  lime,  renal  cal- 
culi may  be  as  variable  as  those  to  be  considered  in  connection  with  dis- 
eases of  the  bladder. 

The  syin2?toins  of  stone  in  the  pelvis  or  the  kidney  are  referalde  to 
the  degi-ee  of  inflammation  (pyelitis)  caused  by  its  presence,  and  to  the 
interference  with  the  escape  of  urine  into  the  ureter.  The  condition  of 
pyelitis  is  in  gi'eat  part  determined  by  the  shape  and  composition  of  the 
calculus. 

A  mulberry  calculus  (oxalate  of  lime)  produces  here,  as  in  the  blad- 
der, a  more  acute  and  therefore  more  perceptible  inflammatory  process 
than  the  smooth  uric-acid  or  phosphatic  stones.  Stones  with  smooth 
surfaces  and  of  slow  formation  may  remain  months  in  the  pelvis  with- 
out causing  a  disturbance  sufficient  to  attract  the  attention  of  the  patient 


GENITO-URIXARY  ORGANS.  559 

or  physician.  This  is  especially  tnie  if  the  body  does  not  drop  into  the 
opening  of  the  ureter.  Sudden  occlusion  of  this  tube  produces  symp- 
toms of  general  disturbance.  If  the  stone  is  small  and  smooth,  it  may 
pass  into  the  outlet  and  find  its  way,  by  gravity  and  the  pressure  of 
urine  from  behind,  into  the  bladder  without  attracting  the  attention  of 
the  patient.  When  a  rough  stone,  or  one  large  enough  to  distend  the 
tube  enters  the  ureter,  symptoms  of  a  more  than  usually  painful  nature 
appear.  The  pain  is  usually  referred  to  the  neighborhood  of  the  im- 
pacted substance ;  it  is  violent  to  a  degree  rarely  experienced  in  any 
other  aifection.  It  may  be  spasmodic  or  constant.  In  males  the  testicle 
of  the  affected  side  is  drawn  up  toward  the  external  ring,  and  not  infre- 
quently the  pain  is  felt  in  this  organ,  in  the  scrotum,  penis,  and  down 
the  thigh  and  leg.  Vomiting  may  be  present,  and  constipation  is  the 
rule.  Suppression  of  urine  follows  in  a  small  proportion  of  cases,  and, 
on  the  other  hand,  in  some  instances  the  quantity  excreted  is  greater 
than  nonnal.  In  the  majority  of  cases  red.  blood-disks  may  be  found  in 
the  urine.  The  duration  of  the  attack  varies  from  a  few  hours  to  days. 
When  the  stone  escapes  into  the  bladder,  the  relief  is  as  sudden  as  the 
attack.     In  rare  instances  it  becomes  hopelessly  impacted. 

The  treatment  of  renal  calculus  is  practically  palliatite.  The  diath- 
esis of  the  individual  must  be  corrected.  The  diet,  mode  of  life,  and 
surroundings  which  produce  one  stone  in  the  kidney  will  cause  the  same 
lesion  indefinitely.  The  character  of  the  urine  must  be  carefully  studied 
and  an  effort  made  to  dissolve  the  concretion  in  the  pelvis.  The  object 
of  this  plan  is  to  carry  in  contact  with  the  stone,  through  the  agency  of 
the  blood,  certain  reagents  which  are  known  to  effect  the  dissolution  of 
these  concretions.  The  citrate  of  potash,  in  doses  of  from  grs.  xx-xxx, 
is  a  favorite  remedy.  It  is  especially  commended  in  the  iiric-acid  cal- 
culus, and  should  be  given  several  times  a  day,  freely  diluted  with 
water  or  flax-seed  tea,  and  continued  for  several  months.  In  phosphatio 
calculi  the  benzoate  of  ammonia,  in  doses  of  grs.  v-xx,  should  be  em- 
ployed. 

A^Tien  renal  colic  occurs,  the  chief  indication  is  to  alleviate  pain,  and 
for  this  purpose  the  hypodermic  use  of  morjihia  is  most  efficient.  Ether 
narcosis  may  also  be  employed  where  morphia  or  opium  is  contraindi- 
cated.  Pain  is  not  only  allayed  by  this  means,  but  the  relaxation  of 
the  muscular  elements  of  the  ureters  secured  and  the  passage  of  the 
calciilus  greatly  facilitated.  In  case  the  calcuhis  becomes  permanently 
lodged  in  the  ureter,  the  operation  of  nephrectomy  may  be  necessitated. 
This  procedure  will  be  described  hereafter. 

Cysts. — In  addition  to  the  form  of  cyst  which  is  caused  by  obstruc- 
tion beycmd  the  pelvis  of  the  kidney,  there  may  exist  smaller  cysts 
within  the  substance  of  this  organ  resulting  from  occlusion  of  one  or 
more  of  the  tubules.  These  cysts  are  usually  small.  When  the  obstruc- 
tion occurs  near  the  apex  of  a  pyramid,  the  entire  tubular  structure  of 
that  pyramid  may  be  destroyed.  Hydatid  cysts,  due  to  the  lodgment 
of  the  ova  of  the  toenia  echiaococeus,  are  occasionally  met  with  in  the 
kidney. 


560  A  TEXT-BOOK   ON   SURGERY. 

The  symptoms  of  renal  cyst  are  usually  obscure  until  the  tumor  be- 
comes large  enough  to  exercise  pressure  on  neighboring  viscera  or  to 
appear  as  a  swelling  in  the  lumbar  region.  Fluctuation  or  asi)iration 
will  determine  the  cystic  cliaracter  of  the  tumor. 

The  treatment  of  renal  cysts  is  conservative  so  long  as  life  is  not 
endangered  by  the  pressure  of  the  tumor.  The  danger  of  ruptuie  into 
tlie  peritontBum  is  not  to  be  overlooked  as  a  possible  and  fatal  accident. 

Opening  into  the  retroperitoneal  space  is  also  an  exceedingly  danger- 
r)us  comi)lication.  It  may  be  put  down  as  a  safe  rule  of  itractice  that 
when  a  tumor  of  the  kidney  becomes  large  enough  to  be  api)reciated  by 
l)alpation  or  inspection,  and  is  proved  to  be  cystic  in  character,  the  con- 
tents should  be  evacuated  by  incision. 

Carcuioma  may  be  primary  in  the  kidney  or  secondary  by  extension 
from  a  contiguous  organ,  or  by  metastasis.  In  primary  cancer  only  one 
organ  is  affected.  When  the  disease  extends  from  the  bladder  it  is  likely 
to  involve  both  organs,  and  the  same  is  true  of  secondary  deposits  by 
metastasis.  The  adenoid  or  encejdialoid  variety  is  most  frequently  met 
with.  All  ages  are  liable  to  this  disease.  The  tumefaction  is  often  very 
rapid,  and  may  reach  enormous  proportions,  death  resulting  from  asthe- 
nia due  to  the  mechanical  presence  of  the  mass,  as  well  as  to  the  general 
dissemination  of  the  disease. 

The  diagnosis  of  cancer  of  tlie  kidney  will  depend  upon  the  appre- 
ciation of  the  tumor  and  a  careful  study  of  the  history  of  the  case.  The 
differentiation  betveeen  the  solid  and  cystic  tumors,  which  has  already 
been  given,  will  eliminate  hydatids  or  obstruction  to  the  outflow  of 
urine  and  cystic  degeneration.  The  recognition  of  the  cancer  must  de- 
pend upon  the  presence  of  the  peculiar  cachexia.  The  treatment  should 
he  directed  to  the  alleviatif)n  of  pain.  The  removal  of  the  organ  is 
scarcely  justifiable,  since  metastasis  will  in  great  probability  have  oc- 
curred before  the  character  of  the  disease  can  be  recognized. 

Sarcoma  of  the  kidney  is  a  ra:-e  fomi  of  disease,  and  this  is  espe- 
cially true  of  primary  sarcoma.  The  presence  of  this  neoplasm,  danger- 
ous in  any  portion  of  the  economy,  is  especially  so  in  the  kidney,  where 
its  deep  location  renders  an  early  diagnosis  almost  impossible. 

Adenoma^  lympliadenoma.,  and  jiupilloma  may  also  be  found  in  this 
organ.  Adenoma  and  papilloma  can  scarcely  be  recognized.  The  same 
may  be  said  of  lymphadenoma,  as  far  as  the  kidney  proper  is  concemed, 
for  it  can  scarcely  be  recognized  during  life,  the  diagnosis  depending 
upon  the  general  condition  of  lymphadenoma  and  leucsemia.  Anyio- 
mata  of  the  cavernous  variety  has  been  noted  in  the  kidney  in  rare  in- 
stances. Rhabdomyoma  of  the  kidney,  an  uniisual  form  of  neoi)lasm. 
which  has  lately  been  described,  may  be  also  mentioned  here.  It  is  sup- 
posed to  be  congenital,  and  is  composed  of  striped  muscle-tissue. 

Siijjpression  of  Urine. — Xot  infrequently  after  a  surgical  operation, 
especially  upon  the  rectum  and  genito-urinary  organs,  the  function  of 
the  Iddneys  is  partially  or  completely  suspended.  Suppression  may  also 
follow  an  injury  to  any  portion  of  the  body,  or  any  violent  emotion.  It 
may  occur  in  patients  with  healthy  kidneys,  but  is  especially  ajit  to  be 


GENITO-URINARY   ORGANS.  561 

met  with  in  individuals  who  suffer  from  acute  or  chronic  nephritis.  It 
is  always  fraught  with  great  danger,  demanding  immediate  relief,  in  the 
hope  either  of  restoring  the  function  of  these  organs  at  once,  or  of  in- 
ducing a  compensatin-y  elimination  of  urea  and  the  i>roducts  of  tissue- 
waste  by  the  skin  and  mucous  surfaces. 

The  s>/mptoms  are  unnatural  dryness  and  heat  of  the  skin  ;  high 
febrile  movement ;  quick,  distended  pulse  ;  at  times,  headache  ;  pain  in 
the  lumbar  region  ;  deluium,  coma,  and  convulsions.  These  graver  symp- 
toms are  usually  observed  in  the  latter  stages  of  complete  suppression. 
If  not  relieved,  the  exhalations  from  the  skin  and  air-passages  have  the 
odor  of  urine.  Lastly,  though  not  least  in  importance  in  diagnosis,  is 
the  absence  of  urine  detei-mined  by  catheterization. 

In  all  surgical  operations  the  condition  of  the  kidneys  can  not  be  too 
closely  studied  or  too  carefully  watched.  While  nephritis,  pyelitis,  or 
any  kidney  lesion  should  not  deter  the  surgeon  from  a  necessary  opera- 
tion, it  should  render  his  prognosis  more  guarded,  and  thus  relieve  him 
in  great  part  from  the  responsibility  of  failure. 

The  immediate  indication  in  the  treatment  of  suppression  is  chieliy  to 
excite  diaphoresis.  Opium  is  a  valuable  remedy,  for  it  not  only  relieves 
pain,  which  is  at  times  intense,  but  excites  perspiration.  The  steam- 
bath  is  also  very  useful,  and  should  be  given  in  the  recumbent  posture. 
A  ready  method  is  to  generate  the  vapor  in  a  tea-kettle  and  lead  the  steam 
under  the  bedclothes  by  a  piece  of  tubing.  Or  hot  water  may  be  poured 
into  a  large  vessel  placed  under  the  blanket  which  is  next  to  the  patient. 

Next  to  diaphoresis,  mild  purgation  is  advisable,  although  it  should 
not  be  carried  to  the  extent  of  exhaustion.  The  cautious  employment 
of  the  muriate  of  pilocarpin  is  justifiable  in  extreme  cases.  The  depress- 
ing effect  of  this  drug  upon  the  heart  should  not  be  overlooked.  The 
dose  should  not  be  more  than  one  twelfth  of  a  grain,  hypodermically,  and 
repeated  in  half  an  hour  if  necessary.  The  hot-bath  should  be  admin- 
istered at  the  same  time.  If  there  are  no  sj'mptoms  of  acute  nephritis, 
and  if  the  kidneys  do  not  resume  their  function  within  a  feAv  hours,  diu- 
retics should  be  given.  A  decoction  of  scoparius,  or  extract  of  buchu, 
will  be  found  useful. 

Operation  for  exploring  the  Kidney  and  for  its  Removal. — When 
the  kidney  becomes  the  seat  of  any  disease  which  is  progressive,  and 
which,  in  the  opinion  of  the  surgeon,  will  immediately  or  remotely  en- 
danger the  life  of  the  patient,  operative  interference  is  indicated. 

Exploration  witti  the  Aspirator-Needle. — In  operations  upon  these 
organs  the  following  anatomical  points  should  be  borne  in  mind :  By 
reason  of  tlie  large  size  of  the  liver,  the  right  kidney  occupies  a  position 
about  one  inch  lower  than  the  left ;  anteriorly  it  is  partially  overlapped 
by  this  organ  ;  its  lower  end  is  a  little  below  the  level  of  the  umbilicus  ; 
the  ascending  colon  is  in  front.  The  left  kidney  has  in  front  of  it  the 
descending  cok)n  ;  the  spleen  at  times  may  overlap  its  upper  end ;  its 
lower  end  is  a  little  above  the  level  of  the  umbilicus. 

In  exploring  a  diseased  kidney  percussion  will  serve  to  locate  the 
colon  so  tliat  it  may  be  avoided.  If  fluctuation  is  present,  the  point  at 
86 


562  A  TEXT-BOOK  ON  SURGERY. 

which  it  is  most  superficial  should  be  selected  for  puncture.  In  general, 
the  organ  will  ])e  reached  most  safely  three  and  a  half  inches  from  the 
spines  of  tlie  vertebra'. 

If  an  exploratory  aspiration  demonstrates  the  presence  of  fliiid  (other 
than  blood),  an  incision  should  follow,  for  the  reason  that  the  escape  of 
liquid  into  the  letropt'ritoncal  space",  or  into  the  jieritoiiaMiiii,  is  a  danger 
to  be  avoided  by  incision  and  drainage  through  the  lumbar  region. 

Nephrotomy  is  performed  by  making  an  incision  fi-om  the  last  lib  to 
near  the  iliac  crest,  parallel  to  and  three  and  a  h;df  inches  from  the  ver- 
tebral spines.  JJividing  the  integument,  fascia?,  and  fat,  the  edge  of  the 
quadratus  lumbornm  is  sought,  and  the  ajxmeurotic  extension  of  the 
transversalis  muscle  divided,  when  the  linger  can  be  passed  into  the  re- 
troperitoneal space  behind  the  colon  and  directly  upon  the  kidney.  All 
haemorrhage  should  be  arrested  as  it  occurs.  •  By  drawing  the  edges  of 
the  wound  wide  apart  with  llat  retractors,  the  fatty  capsule  may  be  sepa- 
rated with  the  lingers  or  liandle  of  the  scalpel,  and  the  exact  condition 
of  the  organ  determined.  If  an  abscess  be  discovered,  or  any  lesion  de- 
manding incision  and  drainage,  this  should  be  done. 

If  the  pelvis  is  blocked  with  stone,  or  if  there  is  a  calculus  in  the 
kidney,  which  may  be  determined  by  digital  exploration,  it  should  lie 
removed  by  incision.  The  operation  is  known  as  nephrolithotomy.  The 
incision  should  be  left  open  and  drained.  When  the  kidney  has  suffered 
displacement,  and  is  causing  distress  by  dragging  upon  its  vessels,  if  it 
is  otherwise  normal  it  should  be  carried  as  nearly  into  its  former  posi- 
tion as  possible  and  its  capsule  stitched  to  the  edges  of  the  wound 
through  the  abdominal  walls.  Catgut  sutui'es  of  large  size  should  be 
used,  and  these  passed  well  into  the  fatty  capsule  which  surrounds  this 
organ.  The  fibrous  capsule  proper  of  the  kidney  should  not  be  perfo- 
rated by  the  needle.  The  patient  must  be  kept  in  the  dorsal  decubitus 
until  adhesions  have  been  formed  sufficient  to  hold  the  organ  in  place. 

Nephrectomy,  or  removal  of  the  kidney,  has  been  successfully  per- 
formed so  often  of  late  years  that  its  advisability  in  certain  diseases  of 
this  organ  is  unquestioned.  Before  undertaking  this  ojieration  the  pre- 
caution should  be  observed  of  determining  not  only  the  presence  of  a 
second  organ,  but  its  condition.  A  fatal  result  has  followed  the  removal 
of  a  single  or  "horse-shoe"  kidney.  It  is  equally  important  to  deter- 
mine, if  possible,  whether  the  opiwsite  organ  is  capable  of  carrying  on 
the  necessary  excretion  of  urine.  The  presence  of  a  second  organ  may 
be  made  out  by  palpation.  That  it  is  performing  its  function  satisfac- 
torily may  be  determined  by  a  quantitative  and  qualitative  analysis  of 
the  iirine  discharged.  The  quantity  of  the  fluid  and  urea  eliminated 
ahould  approximate  the  noi-mal.  If  albumen  is  present,  and  there  is  no 
pus  in  the  urine,  the  gravity  of  the  prognosis  is  increased.  Anj^  symp- 
toms of  urfemia  should  contraindicate  the  oiieration. 

The  organ  is  reached  by  the  same  incision  given  for  nephrotomy. 
When  necessary  to  secure  the  vessels  at  the  hilus,  the  wound  may  be 
enlarged  bj'  a  limited  transverse  incision.  All  bleeding  should  be  ar- 
rested as  it  occurs.     When  the  fatty  capsule  is  reached,  it  should  be 


GENITO-URINARY  ORGANS.  563 

scratched  through  with  the  finger-nail,  or  torn  between  two  forceps.  As 
soon  as  the  hilus  is  exposed,  the  vessels  should  be  tied  with  doul)le-strong 
silk  threads,  divided  between  the  ligatures,  and  the  organ  removed.  The 
wound  should  be  irrigated  with  sublimate  solution,  drainage-tubes  in- 
serted, and  an  antiseptic  dressing  applied. 

The  Ureters. — The  diseases  which  afTect  the  ureters  do  not  demand 
especial  consideration.  The  inflammatory  jjrocesses  are  those  which  ex- 
tend downward  from  the  pelvis  of  the  kidney  or  upward  from  the  blad- 
der. The  same  may  be  said  of  neoplasms.  Partial  or  complete  occlusion 
from  pressure  within  the  canal,  as  from  a  migrating  or  impacted  calcu- 
lus, or  by  pressure  from  a,  tumor  from  without  (as  by  an  aneurism  or 
neoplasm),  may  demand  surgical  interference. 

Bladder. — Among  the  congenital  lesions  of  the  bladder  to  which  the 
attention  of  the  surgeon  is  called,  exstrophy  is  most  frequently  observed. 
More  rarely  there  are  several  sacs,  each  with  a  ureter,  or  there  may  be  a 
central  septum  dividing  the  bladder  into  two  chambers  of  about  equal 
size,  with  a  ui-eter  emptying  into  each.  The  bladder  is  at  times  absent, 
the  ureters  opening  into  the  alimentary  canal,  vagina,  or  perina?um,  or 
into  the  pelvis,  at  a  point  corresponding  to  the  nonnal  position  of  the 
bladder. 

Exstrophy^  or  eversion  of  the  bladder,  is  almost  always  met  ^^ath  in 
males.  It  is  caused  by  a  failure  of  development  in  the  anterior  pelvic 
and  abdominal  regions.  The  integument,  muscles,  pubic  bones,  and 
anterior  part  of  the  bladder- wall  are  missing.  Through  this  gap  the  part 
of  the  bladder  which  may  be  present  is  protruded,  as  a  mass  of  variable 
size  (depending  upon  the  extent  of  the  deformity  and  upon  the  position 
of  the  patient),  from  one  inch  up  to  three  or  four  inches  in  diameter.  In 
the  erect  posture  it  is  always  largest,  being  pushed  out  by  the  descent 
of  the  abdominal  viscera,  and  complicated  by  hernia  of  the  intestine. 
The  mucous  membrane,  which  covers  the  mass,  is  in  appearance  not  un- 
like a  recent  non-strangulated  prolapsus  am.  The  orifices  of  the  ureters 
may  be  found  opening  at  some  jjoint  on  the  lower  portion  of  the  protru- 
sion, and  are  often  considerably  dilated.  In  all  cases  of  exstrophy  the 
genital  apparatus  is  rudimentary.  The  penis  is  wholly  or  in  great  part 
wanting.  The  urethra  may  be  seen  as  a  simple  groove,  into  which  the 
seminal  ducts  enter.  The  scrotum,  at  times  entirely  absent,  may  in  other 
cases  be  present,  lodging  the  testicles,  or  it  may  be  bifid,  with  one  organ 
in  each  sac,  or  entirely  missing,  the  testes  remaining  in  the  abdomen,  or 
lodged  in  the  gi'oin  or  thigh. 

The  degree  of  exstrophy  varies  in  proportion  to  the  extent  of  the 
malformation.  In  the  more  favorable  cases  the  pubic  bones  are  almost 
united  at  the  symphysis,  and  the  protrusion  consequently  small. 

In  females  the  genital  organs  are  also  rudimentary.  The  clitoris, 
nymphse,  vagina,  and  uterus  may  be  absent  or  disj)laced,  and  only  par- 
tially develojied.  The  general  appearances  of  the  tumor  are  the  same  in 
both  sexes. 

Exstrophy  of  the  bladder,  even  in  a  mild  form,  is  a  source  of  great 
annoyance. 


564 


A   TEXT-BOOK   ON   SURGERY. 


Fio.  564. 


The  treatment  is  chiefly  ])alliative,  and  consists  in  the  api)lication  of 
an  appai-atus  to  drain  the  urine  off  and  prevent  excoriations.  A  suitable 
instrument  is  shown  in  Fig.  504. 

The  operative  treatment  consists  in  an  effort  to  cover  in  the  protruding 
mass  by  integument  borrowed  from  the  immediate  vicinity  of  tlie  tumor. 

No  definite  line  of  procedure  can  be  advised. 
The  skin  may  be  turned  from  the  abdomen, 
thighs,  and  perina'iim.  The  operati(»n  is  not 
without  danger  to  life,  and,  when  not  fatal,  fre- 
quently fails  to  benefit  the  patient.  The  chief 
difficulty  lies  in  protecting  the  flaps  from  con- 
tact with  the  urine.  To  obviate  this,  the  pro- 
cedure of  Levis  more  nearly  meets  the  indica- 
tions. It  consists  in  establishing  a  false  urethra 
from  that  portion  of  the  partly  developed  blad- 
der near  the  orifices  of  the  ureters  through  to 
the  perina?um. 

A  large  and  long  needle,  armed  with  a  good- 
.sized  thread  or  wire,  is  carried  through  the  wall 
of  the  bladder,  just  at  the  openings  of  the  ure- 
ters, and  brought  out  in  the  perinseum,  about  an 
inch  in  front  of  the  anus.  The  wire  is  allowed 
to  remain  as  a  seton,  and  through  the  fistula 
thus  established  the  urine  begins  to  How.  The  false  urethra  is  enlarged, 
by  gradual  dilatation  with  bougies,  until  it  is  of  sufficient  size  to  carry 
off  all  the  urine.  When  this  is  accomplished,  the  second  stage  of  the 
operation  consists  in  covering  the  exstrophy  with  integument  turned  over 
from  the  immediate  neighborhood  of  the  deformity.  In  males,  one  in- 
cision may  be  earned  from  near  the  center  of  Poupart's  ligament,  curving 
downward  along  the  inner  side  of  the  thigh,  across  the  scrotum  or  peri- 
nseum,  as  the  case  may  demand,  and  terminating  at  a  corresponding  jjoint 
upon  the  opposite  side.  This  flap  is  dissected  up  toward  the  edges  of  the 
exstrophy,  leaving  a  line  of  attachment  sufficient  to  sup])ly  nutiition  to 
it.  A  second  flap  is  turned  down  from  the  abdomen,  and  the  two  are 
sewed  together,  the  raw  surfaces  l)eing  now  external,  while  the  epidermis 
is  internal,  and  in  contact  with  the  mucous  surface  of  the  deformed  blad- 
der. If  the  penis  is  sufficiently  developed,  a  hole  should  be  cut  in  the 
lower  flap  and  this  organ  drawn  through.  The  outer  raw  surface  may  be 
left  alone  to  cicatrize,  although  it  should  be  covered  over  at  a  subsequent 
operation,  if  there  is  enough  integument  left  to  borrow  from.  If  not,  the 
granulating  surface  may  be  covered  with  grafts. 

In  females  the  same  method  of  operation  may  be  used,  modifying  the 
flap  to  suit  the  deformity,  and  to  preserve  as  much  of  the  functions  of  the 
genital  organs  as  possible. 

Hernia  Vesicce,  or  Cystocele. — Hernia  of  the  bladder  is  a  very  rare 
accident.  It  is  more  apt  to  occur  in  connection  with  a  perforating  wound 
of  the  pelvis  or  supra-pubic  region.  Idiopathic  cystocele  occurs  chiefly 
in  the  aged,  and  in  those  who  have  atony  of  the  walls  of  this  organ  from 


GENITO-URINARY  ORGANS.  565 

habitual  retention  of  urine,  and,  at  the  same  time,  some  form  of  intestinal 
hernia.  The  bladder  becomes  top-heavy  and  flabby,  and  readily  pro- 
lapses into  the  patulous  inguinal  or  femoral  canal,  as  the  case  may  be. 

The  diagnosis  is  evident  if  the  tumor  diminishes  with  the  evacuation 
of  the  organ  by  catheterization,  and  becomes  distended  by  injection 
through  the  urethra.  If  it  should  become  strangulated,  asjiiration  with 
the  finest  needle,  and  microscopic  examination  of  the  fluid  withdrawn, 
will  confirm  the  diagnosis  of  cystocele. 

Treatment. — Hernia  of  the  bladder  should  be  reduced  by  taxis,  and 
prevented  from  recurrence  by  a  truss.  If  it  shoiild  become  strangulated, 
and  gangrene  occur,  an  incision  should  be  made,  and  the  wound  treated 
antiseptically.  A  fistula  resulting  from  this  practice  will  close  by  granu- 
lation, or  can  be  cured  by  a  subsequent  operation. 

Wounds. — A  solution  of  continuity  in  the  walls  of  the  bladder  may 
be  caused  by  penetration  from  without,  as  in  the  case  of  a  shot-  or  stab- 
wound,  by  rupture  from  over-distention,  by  violent  concussion,  or  by 
direct  injury  from  displaced  fragments  of  bone  in  fractures  of  the  pel- 
vis. Penetrating  wounds  of  the  bladder  are  rare,  not  only  on  account  of 
the  protection  afforded  by  the  pelvic  bones,  but  because  its  usual  condi- 
tion is  that  of  only  partial  distention.  This  is  especially  true  of  wounds 
received  in  military  practice,  since  soldiers  going  into  action  almost  in- 
variably empty  this  organ. 

The  diagnosis  of  a  penetrating  wound  of  the  bladder  depends  upon 
the  escape  of  urine  through  the  opening,  or  the  sudden  appearance  of 
blood  or  particles  of  clothing,  or  other  foreign  matter,  in  the  urine. 
Shock  is  usually  profound.  Haemorrhage  is  not  severe,  unless  some  of 
the  iliac  arteries  or  their  larger  branches  are  involved. 

The  prognosis  is  always  grave,  though  not  necessarily  fatal.  The 
immediate  danger  is  from  haemorrhage  and  shock.  Peritonitis  is  in- 
evitable if  the  wound  is  above  the  attachment  of  this  membrane  to 
the  bladder.  If  below  this  line,  the  infiltration  will  lead  to  pelvic 
cellulitis. 

The  indications  in  treatment  are  to  arrest  hsemorrhage,  and  to  prevent 
infiltration  and  sepsis  by  free  incision  and  drainage.  When  the  large 
vessels  of  the  pelvis  are  wounded,  an  effort  should  be  made  to  arrest  the 
bleeding  by  compression  and  the  ligature. 

If  extravasation  of  urine  into  the  cavity  of  the  peritonjpum  has  taken 
place,  the  abdomen  should  he  opened  and  thoroughly  irrigiited  with  warm 
Thiersch's  solution.  If  this  is  not  convenient,  warm  sublimate  solution, 
1  to  20000,  may  be  employed,  or  warm  water.  The  entire  cavity  should 
be  filled  with  the  fluid,  and  should  afterward  be  thoroughly  dried  out 
with  clean,  soft  sponges.  In  a  case  which  came  under  my  observation, 
the  bladder  was  wounded  at  its  summit,  and  urine  escaped  freely  into  the 
cavity  of  the  peritonaeum.  Tlie  abdomen  was  flooded  with  l-to-200()0 
sublimate  solution,  and  carefully  sponged  out.  The  patient  recovered 
without  a  symptom  of  peritonitis.  In  this  case  the  edges  of  the  incision 
in  the  linea  alba  were  held  open  by  retractors,  and  the  warm  solution 
poured  in  from  a  pitcher. 


566 


A  TEXT-BOOK   ON   SURGERY. 


If  tile  wound  iii  ihr  l)lii(kk'r  is  so  situated  that  its  edges  can  be  stitched 
to  the  edges  of  the  opening  in  the  abdomen,  this  should  be  done.  Silk 
sutures  should  l)e  enii)!(>ye(l,  and  the  needle  passed  thi'dugh  the  integu- 
ment, and  then  thnxigh  the  muscular  layers  of  the  bladder,  down  to  the 
mucous  lining.  It  is  safer  not  to  penetrate  entirely  through  the  wall. 
The  urin(>  is  discharged  tlirougli  the  wound,  for  a  variable  time,  until  it 
closes  by  granulation. 

When  it  is  impossible  to  bring  the  edges  of  the  wound  in  the  bladder 
up  to  the  abdominal  wall,  it  should  be  (-losed  at  once.  Fine  interrupted 
silk  sutures  should  be  inserted,  about  one  eighth  of  an  inch  apart.  They 
siiould  be  introduced  after  the  method  of  Lembert  in  suture  of  the  intes- 
tines. The  drainage-tube  of  Dr.  H.  Marion-Sims  should  be  em])loyed,  as 
a  precaution  against  peritonitis.  In  the  after-treatment  it  is  ini])ortant 
that  the  urine  be  drawn  with  the  catheter,  at  frequent  intervals,  and  over- 
distention  thus  prevented. 

If  the  wound  is  situated  at  the  symphysis,  and  is  extra-peritoneal,  ita 
edges  should  be  stitched  to  the  integument  as  above,     ^\'hen  the  wound 

is  through  the  perineal  region, 
free  incision  should  be  made  at 
once,  in  order  to  divide  all  the 
muscles  and  fascise  down  to  the 
bladder,  so  that  tlie  urine  may 
escape  to  the  outside  without 
infiltration.  In  these  cases  re- 
covery takes  place  in  the  same 
way  as  after  lithotomy. 

Rupture  of  the  Bladder. — 
This  accident  is  much  more  fre- 
quent with  men  than  women. 
When  occurring  in  females  it  is 
usually  during  parturition,  or 
from  continuous  pressure  of  this 
organ  by  uterine  or  ovarian  tu- 
mors. Obstruction  of  the  ure- 
thra is  the  chief  cause  of  idio- 
pathic rupture.  In  enlarged 
prostate,  or  close  stricture  of 
long  standing,  the  bladder  be- 
comes gradually  accustomed  to 
the  presence  of  an  abnormal 
quantity  of  urine,  its  walls  be- 
come thin  and  weak  under  the 
jirocess  of  dilatation,  until,  af- 
ter a  sudden  excessive  accumu- 
lation, rupture  occurs.  In  rare 
instances  the  bladder-waU  is 
weakened  by  ulceration  to  such  an  extent  that  it  gives  way.  Eupture 
of  a  diseased  or  normal  bladder  may  follow  a  violent  concussion,  espe- 


Fio.  .5f)5. — The  relations  of  the  peritonaeuia  to  the  blad- 
der when  dUtcnded.  (After  Tinnier.)  1,  The  situ- 
ation of  the  trii-'onum  vesicae.     2,  Prostatic  urethra. 


GENITO-URINARY  ORGANS.  567 

cially  if  the  organ  be  fully  or  partially  distended,  and  tlie  blow  inflicted 
over  the  lower  abdominal  region.  Fracture  of  the  pelvis  is  not  infre- 
quently complicated  with  this  grave  accident.  Fragments  of  bone  may 
be  driven  through  the  walls  of  the  bladder,  or  the  rupture  may  occur 
from  compression  alone. 

The  location  of  the  rupture  is,  fortunately,  in  the  majority  of  cases, 
thrcjugh  portions  of  the  organ  not  covered  by  peritongeum.  The  anterior- 
inferior  or  sub-pubic  portion  and  the  neighborhood  of  the  trigonum  vesi- 
cse  are  most  apt  to  give  way. 

The  symptoms  of  rupture  are  not  always  prominent.  When  violence 
may  be  eliminated,  there  is  usually  a  history  of  over-distention,  a  desire 
to  urinate,  a  feeling  as  if  something  had  given  way,  with  partial  or  com- 
plete relief  from  the  pressure  within  the  bladder.  When  the  rupture  is 
extra-peritoneal,  the  signs  of  infiltration  in  the  perinseum  and  j^erirectal 
tissues  are  early  recognized.  Direct  external  palpation,  or  the  introduc- 
tion of  the  finger  into  the  rectum,  will  recognize  the  doughy  condition  of 
the  tissues.  If  the  hyjiodermic  needle  is  introduced,  a  few  drops  of 
bloody  urine  may  be  withdrawn.  When  the  napture  is  so  situated  that 
urine  escapes  into  the  peritoneal  cavity,  the  earlier  signs  are  shock,  of  a 
severe  tyjie,  with  dullness  on  j)ercussiou  in  the  hypogastric  and  inguinal 
regions.  In  confirming  a  diagnosis  based  upon  any  of  the  foregoing 
symptoms,  an  examination  of  the  bladder  by  the  sound  or  catheter  is 
essential.  The  passage  of  this  instrument  through  an  opening,  so  that 
it  maybe  felt  beneath  the  abdominal  walls,  is  a  demonstration  of  rupture. 
The  passage  of  a  small  amount  of  bloody  urine,  with  or  without  the 
catheter,  is  a  suspicious  sign,  and  if  this  small  quantity  is  passed  with 
each  respiratory  act  the  evidence  is  almost  convincing.  The  exploration 
of  the  pelvic  region  with  the  aspirator-needle  will  determine  the  presence 
of  urine  in  the  tissues  outside  of  the  bladder. 

Treatment. — In  extra-peritoneal  rupture  immediate  and  free  incision 
should  be  made  into  the  infiltrated  zone,  and,  while  this  is  being  done 
under  ether,  the  bladder  should  be  incised  as  in  lateral  lithotomy.  The 
free  escape  of  urine  tlux)Ugh  this  incision  arrests  infiltration  and  keeps 
the  bladder  in  repose,  thus  facilitating  a  closure  of  the  rupture. 

The  treatment  of  rupture  of  the  l)ladder  into  the  cavity  of  the  peri- 
ton?eum  has  just  V)een  given  in  penetrating  wounds  of  this  organ. 

The  comparatively  slight  risk  involved  in  an  exploratory  incision 
througli  the  linea  alba  into  the  cavity  of  the  peritonjeum  should  encour- 
age the  surgeon,  even  in  cases  in  which  tliere  may  be  some  doubt  as  to 
the  correctness  of  the  diagnosis,  to  perform  this  operation.  The  knowl- 
edge that  death  has  so  far  resulted  in  every  case  of  intra-peritoneal  rupt- 
ure of  the  bladder  in  which  surgical  interference  has  not  been  made, 
adds  an  additional  justification  to  the  exploration  of  this  cavity. 

Cifstitis. — Inflammation  of  the  bladder  is  one  of  the  most  common 
surgical  diseases.  It  may  be  acute  or  chronic.  In  the  majority  of  in- 
stances only  the  mucoiis  membrane  of  the  neck  and  floor  of  this  organ 
is  affected.  Less  frequently  the  entire  mucous  lining  is  attacked.  In 
extreme  cases  the  inflammation  attacks  the  muscular  walls,  and  spreads 


568  A  TEXT-BOOK   ON   SURGERY. 

to  the  peritona?um  and  ])elvic  fascia.  An  acute  cystitis  ending  in  rapid 
recovery  rarely  leads  to  hyjiertrophy  or  thickening  of  the  walls  of  the 
bladder.  In  cJtronic  cystitis  thickening  is  the  rule.  Hypertrophy  of 
the  bladder  may  be  true  or  false.  In  true  hypertrojjhy  the  thickening 
is  caused  by  an  increase  of  the  muscular  elements  of  the  organ  ;  in  false 
hypertrophy  it  is  due  to  new-formed  connective  tissue,  which  has  in 
great  part  taken  the  place  of  the  muscular  fibers.  When  the  walls  are 
thickened  and  the  cavity  is  smaller  than  nonnal,  the  hyi)ertrophy  is 
called  concentric;  when  the  cavity  is  increased  and  the  walls  thickened, 
eccentric. 

Cystitis  may  be  caused  by  a  l)low  upon  the  lower  portion  of  the  ab- 
domen, or  in  the  perineal  or  ischio-rectal  region,  or  by  the  direct  con- 
tact of  an  instrument  or  any  liquid  or  solid  substance  carried  into  the 
cavity  of  the  bladder.  Intlammation  of  this  organ  always  exists  with 
calculus.  It  may  become  involved  by  extension  of  an  inflammatory 
process  fmm  the  urethra  or  prostate,  from  the  vagina,  the  kidneys,  or 
ureters.  Certain  abnormal  conditions  of  the  urine,  excessive  indulgence 
in  drinking  or  eating,  the  pressure  of  another  organ  or  a  neoplasm,  or 
the  presence  of  a  new  formation  or  parasites  ^^^thin  the  cavity  or  in  the 
walls  of  this  viscus  {Bilharzia  7i(ematobia),  etc.,  may  also  produce  cys- 
titis. To  these  various  causes  may  be  added  stricture  of  the  urethra  or 
the  prolonged  retention  of  urine. 

Si/mptoms  and  Diagnosis. — Pain,  and  a  de.sire  to  urinate  frequently, 
are  the  earliest  signs  of  acute  cystitis.  The  character  of  the  pain  is 
burning  as  felt  in  the  bladder  and  deep  m-ethra,  and  lancinating  as  re- 
ferred to  the  meatus.  It  often  increases  with  the  close  of  the  effort  at 
urination,  developing  into  marked  tenesmus  as  the  last  few  drops  are 
forced  out.  It  is  exaggerated  by  direct  pressure  upon  the  abdomen,  in 
the  periiueum.  rectum,  or  vagina. 

The  febrile  movement  varies  with  the  severity  of  the  disease.  A  well- 
marked  chill  or  a  succession  of  rigors  may  occur  with  the  rise  in  tem- 
perature and  be  present  at  various  times  in  the  progress  of  the  disease. 
Microscopical  examination  of  the  urine  will  reveal  the  presence  of  epi- 
thelia  and  pus-corpuscles  in  varying  quantity.  The  urine  is  usually 
alkaline,  and,  aside  from  all  diseases  of  the  kidneys,  will  contain  a  cer- 
tain proportion  of  albumen,  which  is  always  found  when  this  fluid  is 
mixed  with  pus.  In  severe  and  unusual  case.s,  shreds  of  bladder-tissue 
may  be  voided  with  the  urine. 

Treatment. — Rest  in  bed,  and  in  that  position  which  gives  the  fullest 
sense  of  comfort  to  the  patient,  is  essential.  When  the  inflammation  is 
confined  to  the  neck  and  anterior  portion  of  the  floor  of  the  bladder,  it 
is  advisable  to  elevate  the  foot  of  the  bed  fi-om  four  to  six  inches,  and 
to  place  a  pillow  under  the  patient's  hips.  By  these  means  the  intes- 
tines and  other  organs  are  carried  by  gravity  away  from  the  diseased 
viscus,  and  at  the  same  time  the  urine  is  to  some  extent  distributed  over 
a  wider  and  less  inflamed  surface. 

Morphine  is  invaluable  in  the  alleviation  of  pain  and  the  enforcement 
of  quiet.     Hot  or  cold  applications — as  found  most  agreeable  to  the  pa- 


GENITO-URIXARY   ORGANS. 


569 


tient — are  useful.  The  free  administration  of  Vichy  water,  or  citrate  of 
potash  (grs.  x-xx)  at  fi-equent  intervals,  is  advisable.  The  rectum  should 
be  thoroughly  emptied  every  day  by  a  cold-water  enema. 

In  chronic  cj-stitis  the  treatment  must  be  directed  to  the  cause  of  the 
disease.     Unfortunately,  it  is  too  often  incurable,  and  then  only  pallia- 
tive measures  may  be  adopted.     In  paralysis  or  atony  of  the  muscular 
walls,  or  in  the  enlarged  pros- 
tate  of    old    men,    retention 
may  be  relieved  by  the  em- 
ployment of  the  soft  catheter, 
and  the  condition  of  the  or- 
gan improved   by  irrigation. 
When  it  is  desired  simj^ly  to 
empty  the    bladder  without 

washing  it   out  afterward,  the   soft-rubber   catheter   of  Xelaton 
566)   should  be  introduced.     An  instrument  of  good  size — Xos. 
14,  U.  S.  scale — with  a  perfectly  smooth  point,  should  be  selected.     It 
should  be  thoroughly  warmed  and  oiled,  and  introduced  with  the  pa- 


FiG.  566. — Xelaton's  catheter. 


(Fig. 
12  to 


Fig.  5G7. — Velvct-t-yed  ^'iim  catheters,  curved  and  straight. 

tient  resting  on  the  back.  It  should  not  pass  beyond  the  neck  of  the 
bladder.  When  it  is  desired  to  irrigate  the  bladder,  the  double-cur- 
rent soft  catheter  (Fig.  568)  should  be  used.  A  warm  solution  of  boracic 
acid  (grs.  x-  3  j  of  water)  is  an  excellent  remedy.  From  one  to  two  pints 
are  poured  into  a  fountain-syringe,  and  a  small  quantity  is  allowed  to 


G.TIEMANN  &  CO. 


Fig.  508. — Double-current  snfi  catheter,  for  irrigating  the  bladder. 


run  out  at  the  end  of  the  tube  to  drive  out  the  air.  The  catheter  is  next 
introduced  down  to  the  constrictor  urethr;e  mu.scle,  when  the  tulie  from 
the  syringe  should  be  connected  with  the  larger  end  of  the  catheter  and 
a  small  quantity  of  water  allowed  to  run  in  until  it  tills  the  instrument 
and  Hows  out  at  the  smaller  tube.  By  this  manoeuvre  the  air  is  com- 
pletely expelled,  and  the  catheter  should  immediately  be  pushed  into 
the  bladder.  The  mechanism  of  this  apparatus  is  such  that  it  permits 
a  constant  and  steady  current  of  water  to  How  in  and  out  of  the  organ 
without  over-distention.  As  soon  as  the  fluid  comes  out  perfectly  clear, 
the  operation  should  ceas(\  It  may  be  repeated  every  day,  and  oftener 
when  necessary.     If  the  double  catheter  can  not  be  obtained,  an  ordi- 


570  A  TEXT-BOOK   ON  SURGERY. 

nary  single  instrument  will  .suilice ;  but  the  exclusion  of  air  is  more  diffi- 
cult. Chronic  cystitis,  due  to  stone  in  the  bladder,  pressure  of  other 
organs  or  a  tumor,  and  stricture  of  the  urethra,  etc.,  will,  ns  a  rule,  dis- 
appear with  the  cure  of  these  various  lesions.    • 

In  cases  which  resist  all  conservative  measures,  incision  through  the 
perinajum,  as  in  the  median  or  lateral  operations  for  stone,  will  be  justi 
fiable.     This  operation  will  be  given  with  affections  of  the  pi'ostate. 

Farali/sis  of  the  bladder  may  be  partial  or  complete.  It  may  be 
caused  by  violence  inflicted  directly  to  the  organ  or  in  its  immediate 
neighborhood,  1)y  pathological  changes  in  its  muscular  tissue,  or  by 
traumatic  or  idiopathic  lesions  of  the  cerelno-spinal  axis  ;  or  it  may 
occur  under  the  influence  of  certain  emotions  in  which  no  lesion  is  rec- 
ognizable. 

A  blow  upon  the  hypogastric  region  has  been  known  to  cause  tempo- 
rary paralysis  of  the  bladder.  The  unskillful  introduction  of  an  instru- 
ment, and  the  prolonged  over-distention  of  the  organ  which  is  common 
in  prostatic  hypertrophy,  will  induce  the  same  condition.  An  operation 
upon  the  geuito-urinary  apparatus  is  almost  always  followed  by  tempo- 
rary paresis  of  this  organ.  Operations  ujjon  other  portions  of  the  econ- 
omy under  prolonged  ether  or  chloroform  narcosis  are  also  frequently 
followed  by  loss  of  function  in  the  bladder.  The  pressure  of  jjarturition 
may  produce  a  like  result.  Severe  concussion  of  the  brain  or  cord,  com- 
pression of  one  or  both  of  these  ganglia  from  fracture  or  displacement 
of  their  bony  envelopes,  hjemorrhage,  aneurism,  or  the  presence  of  neo- 
plasms and  various  pathological  changes  in  the  meninges  and  in  the  gray 
and  white  matter  of  the  cord  and  brain,  will  lead  to  paraly.sis  of  the 
bladder,  varying  in  duration  with  the  severity  of  the  lesion. 

In  the  treatment  of  this  affection  the  first  indication  is  to  prevent 
prolonged  distenticm  of  the  organ  by  catheterization,  which  should  be 
repeated  at  least  twice  in  twenty-four  hours.  If  a  catheter  can  not  be 
introduced,  supra-pubic  aspiration  should  be  practiced.  Cystitis  may 
be  avoided  if  the  urine  is  carefully  and  regularly  draAvn  off.  Attention 
should  next  be  directed  to  the  removal  of  the  cause  of  the  paralysis. 

Retention. — As  just  stated,  paralysis  of  the  muscular  walls  of  the 
bladder  is  a  cause  of  retention  of  urine.  Lesions  of  the  sensory  nerves 
of  this  organ  also  induce  retention,  which  is  proportionate  to  the  loss 
of  sensibility.  The  chief  cause  of  this  condition,  however,  is  some  form 
of  obstruction  at  the  neck  of  the  bladder  or  in  the  urethra.  As  will  be 
seen  in  treating  of  hypertrophy  of  the  prostate,  this  is  a  frequent  cause 
of  retention.  Organic  stricture,  spasm  of  the  constrictor  urethra  (or 
"cut-off")  muscle,  and  mechanical  occlusion  of  the  urethra,  are  also  com- 
mon causes  of  this  affection. 

Diar/nosis. — Distention  of  the  bladder  may  be  determined  by  palpa- 
tion, percussion,  and  exploration.  In  this  condition  it  rises  well  above 
the  level  of  the  symphysis  pubis,  at  times  as  high  as  the  uml)ilicus,  and 
causes  tension  of  the  recti  muscles  or  protrusion  of  the  abdomen.  By 
direct  pressure,  the  desire  on  the  part  of  the  patient  to  urinate  may 
usually  be  increased,  and,  if  the  abdominal  walls  are  thin,  the  spherical 


GENITO-URINARY   ORGANS. 


571 


character  of  the  organ  may  be  recognized.     Upon  percussion,  dullness 
is  present  and  fluctuation  may  be  appreciable. 

In  suppression  of  urine  all  of  these  symi)t()ms  are  absent,  the  skin  is 
usually  hot  and  dry,  the  pulse  rapid  and  full,  and  the  temperature  is 
several  degrees  above  the  normal.  The  introduction  of  a  catheter  or 
puncture  of  the  bladder  with  a  small-sized  aspirator-needle,  just  at  the 
ui)per  level  of  the  symphysis,  will  detennine  the  diagnosis. 


Fig.  SCSI. — Fililbrm  catheter. 

In  treatment,  the  evacuation  of  the  contents  of  the  organ  is  the  im- 
mediate indication.  The  patient  should  be  put  to  bed  and  given  the 
benefit  of  a  full  dose  of  opium.  This  agent  is  useful  in  alleviating  pain, 
in  securing  relaxation  of  the  muscular  elements  of  the  urethra  and  pros- 
tate, and — by  producing 
diaphoresis — in  diverting 
fluids   from   the  kidnevs 

,  ,  *  riG.  670. — Black  iicucli  cutlicter,  l.luut-p'.iuteJ. 

to  the  excretory  appara- 
tus of  the  skin.  A  soft- 
rubber  (Nelaton)  cathe- 
ter should  be  preferred ; 
but,  if  this  can  not  be 
•introduced,  a  lirmer, 
olive-poinied  instrument 
(Fig.  till)  should  be  em- 
ployed. The  silk-woven 
and  gummed  catheter 
(Figs.  ,072  and  i)7;3)  is  also 
a  useftU  instrument,  and 
if,  on  account  of  its  elas- 
ticity, it  can  not  be  introduced,  the  stylet  of  Prof.  Keyes  (Fig.  U74) 
should  be  inserted  into  the  catheter  to  give  it  the  required  stiffness.    The 


Flo.  571. — Black  Frencli  catl;cter,  oUvc-pomtcd. 


Fig.  572. — Gummed  silk-woven  catheter. 


Fia.  573. — Gummed  silk-woven  bougie. 


Fig.  674. — Dr.  Keves's  wire  stvlet. 


^ — o 


metal  catheter  (Fig.  575),  if  properly  constructed  and  carefully  intro- 
duced, can  be  made  to  safely  overcome  any  ordinary  resistance.  It 
should  be  of  heavy  silver,  strong,  perfectly  smooth,  and  should  have  a 
curve  corresponding  to  that  of  the  normal  urethra.  In  size  it  should  cor- 
respond to  No.  10,  12,  or  14,  U.  S.,  and  the  larger  sizes  should  be  preferied. 


572  A  TEXT-BOOK   ON   SirRGERY. 

The  introduction  of  a  metal  catheter  or  sound  thn)U<j;h  the  noi-mal 
urethra  into  the  bladder  is  accomplished  as  follows :  The  patient  is 
placed  upon  the  back,  with  the  lower  extn^nities  parallel  with  the  bodw 
If  r\[  XX  of  a  4-per-cent  solution  of  cocaine  hydrochlorate  are  introduced, 

the  normal  sensibility  will 
^^  be  lost  as  far  back  as  the 

r""^***^*""^"""""^'"''''""^"^'^^      ccmipressor  muscle.     The 
catheter  is  placed  in  water 
F,o.  575.-stro„K  Biivor  catheter.  »*  ^  temperature  of  about 

10.5°  to  110°  F.,  and,  when 
warmed  through,  is  lubri- 
cated with  sweet-oil  or  vaseline.  If  the  operator  is  right-handed,  it  is 
best  to  stand  on  the  left  side  of  and  facing  the  pntient.  The  ])enis  is 
seized  with  the  left  liand  and  held  steady  while  the  end  of  the  catheter  is 
carried  into  the  meatus.  At  this  stage  of  the  procedure  the  shaft  of  the 
sound  is  j^arallel  with  P()U])art\s  ligament,  and,  as  soon  as  the  first  four 
inches  have  passed  into  the  urethra,  while  it  still  descends,  the  handle  is 
gradually  brought  toward  the  median  line.  The  point  is  now  engaged  in 
the  bulb,  or  at  the  anterior  layer  of  the  triangular  ligament,  and  the  shaft 
is  about  perpendicular  to  the  plane  of  the  abdomen.  Without  exercising 
any  force  to  push  the  instrument  in  the  direction  of  the  bladder,  the  han- 
dle is  slowly  and  steadily  carried  downward  until  the  shaft  is  jiarallel 
with  the  anterior  surface  of  the  thighs.  While  this  mananivre  is  being 
effected,  the  point  is  tilted  from  the  floor  of  the  bulb  into  the  membra- 
nous portion  which  offers  the  greatest  resistance,  not  only  because  it  is 
the  narrowest  part  of  the  canal,  but  because  the  compressor-urethrse 
muscle  must  be  overcome.  All  the  time  that  the  instrument  is  being 
pushed  toward  the  bladder  the  penis  should  be  pulled  over  the  catheter, 
for  in  this  way  the  lining  membrane  is  put  upon  the  stretch  and  the  intro- 
duction greatly  facilitated.  When  the  neck  of  the  bladder  is  reached,  the 
instrument  will  usually  have  penetrated  a  distance  of  eight  or  nine  inches. 
It  should  be  borne  in  mind  that  even  a  silver  catheter  is  capaltle  of  doing 
great  damage  to  the  urethra  if  improper  force  is  employed  in  its  intro- 
duction. There  is  usually  no  resistance  except  by  the  comjjressor  mus- 
cle, and  this  is  only  spasmodic.  If  the  jioint  of  the  instrument  is  kept 
well  against  the  obstructicm  by  depressing  the  handle  between  the  thighs, 
it  will  slip  by  with  the  first  relaxation  of  this  muscle.  The  methods  of 
introducing  an  instrument  into  the  bladder  in  a])normal  conditions  of 
the  urethra  and  ])rostate  will  be  given  later. 

If  it  is  found  impossible  to  reach  the  bladder  by  the  urethia.  the 
urine  should  be  evacuated  by  the  aspirator.  The  ajiparatus  shown  in 
Fig  o76  will  give  general  satisfaction.  The  needle  and  entire  instrument 
should  be  carefully  cleansed  and  disinfected  in  l-to-20  carbolic-acid  solu- 
tion, both  before  and  after  it  is  used.  The  smallest  needle  will  suffice. 
If  its  introduction  is  preceded  by  a  small  hypodermic  syringe-needle, 
and  iTl  x-xx  of  4-per-cent  cocaine  are  injected,  the  operation  will  be  pain- 
less. The  pubes  being  shaved  and  disinfected,  and  everything  in  readi- 
ness, the  needle  is  filled  with  the  carbolic-acid  solution  and  closed  by 


GENITO-URINARY   ORGANS. 


573 


tnraing  the  cock  (6,  Fig.  576) ;  the  air  is  exhausted  from  the  receiver  (2) 
by  working  the  pump  (4).  The  patient  should  be  placed  in  the  sitting 
posture,  and  the  needle  introduced 
a  half-inch  above  the  symphysis 
and  pushed  directly  backward  a 
distance  of  two  inches.  The  cock 
is  now  opened,  and  the  urine  Hows 
into  the  bottle.  If  it  becomes  ne- 
cessary to  empty  the  receiver,  the 
stop-cock  should  be  turned  to  pre- 
vent the  entrance  of  air  into  the 
bladder. 

When  the  character  of  the  ob- 
struction or  disease  is  such  that  a 
permanent  urinary  fistida  is  neces- 
sary, this  may  be  made  through 
the  perineeum  or  directly  from  the 
anterior  wall  of  the  rectum  into 
the  base  of  the  bladder.  Of  the 
two  procedures,  the  former  is  pref- 
erable. 

The  incision  is  the  same  as  for 
lateral  lithotomy.  To  prevent  the 
wound  from  closing,  a  soft  cathe- 
ter should  be  earned  through  the 
incision  into  the  bladder  and 
allowed  to  remain  for  several 
weeks.  The  self-retaining  instru- 
ment shown  in  Fig.  577  will  give  the  best  satisfaction.  The  fistula 
will  become  permanent  as  soon  as  its  walls  are  covered  with  epithe- 

lia.  Although  the  annoy- 
ance from  this  condition 
of  incontinence  is  gi"eat,  it 
is  preferable  to  a  vesico- 
G.TiEMANN  S.CO.  ^ctal   fistula,    where    the 

irritation  of  the  bowel  is 

Fig.  577.— Holt's  belf-retaiuiu^'  catheter.  the  CaUSe  of  mucll  discom- 

fort  and  prostration. 


Fig.  576.— Tiemann  &  Co.'s  aspirator. 


Fig.  57S.— Buck's  rectum  trocar. 


The  recto-vesical  operation  is  performed  in  this  way  :  "While  the 
bladder  is  distended,  the  finger  of  the  left  hand  is  oiled  and  introduced 
into  the  rectum  until  the  tip  passes  above  the  prostate.     A  trocar  and 


574  A  TEXT-BOOK   ON  SURGERY. 

caniila  (Fig.  578)  is  guided  along  the  finger  to  a  point  just  l)eyond  the 
prostate,  where  it  is  turned  directly  ii]nvard  and  forced  through  the 
floor  of  the  bladder.  The  trocar  is  withdrawn  and  the  urine  allowed  to 
escape.  If  this  t)pening  is  not  sufficient  to  allow  of  the  satisfactory  dniin- 
age  of  the  bladder,  it  may  be  enlarged. 

Jnroiifiiience  of  Urine. — Incontinence  of  urine  occurs  when  the  com- 
pressor urethrfe  and  the  inusculai-  elements  of  the  prostate  are  j)aralyzed. 
It  is  present  in  a  proportion  of  cases  of  prolonged  over-distention  of  the 
bladder,  the  pressure  from  licliind  ovei'comiug  the  normal  resistance  of 
ther.e  muscles.     Irritation  of  the  bladder  from  any  cause  may  ]iroduce 

tenesmus  of  this  organ  and  consequent  in- 
ability to  retain  the  urin(\  This  is  esjiecial- 
ly  apt  to  occur  in  children  during  sleep,  in 
the  earlier  hours  of  morning,  when  the  blad- 
der is  full. 

Women  are  more  frequently  affecteil  with 
incontinence  than  men,  which  fact  is  ex- 
plained not  only  in  the  better  tone  of  the 
muscular  system  in  males,  but  in  the  absence 
of  the  prostatic  muscle  in  females,  which,  ac- 
|W«'/ /  ^  /'       cording  to  Henle,  is  of  great  aid  in  holding 

C^^/y  iJ  y  the  urethra  closed.      The  general  relaxatiem 

of  the  pelvic  muscles  as  a  result  of  partu- 
vu..  r,79.-Fo,naio  andj^nie  unnais,     ^..^.^^  ^^^  ^^^^  account  for  the  more  frequent 

occurrence  of  incontinence  of  urine  in  women. 

The  palliative  treatment  consists  in  applying  a  urinal  for  the  recep- 
tion of  the  water  as  it  dribbles  away  (Fig.  579). 

Curative  measures  should  be  directed  to  a  removal  of  the  cause  of 
incontinence.  These  wall  be  given  with  the  various  lesions  of  which  it 
is  a  symptom.  In  the  nocturnal  incontinence  of  children  the  habit  may 
be  corrected  by  causing  the  patient  to  be  awakened  and  the  bladder  emp- 
tied once  or  twice  during  the  night. 


NeAV    FoUMATIONS    and   TtTMORS    OF   THE    BLADDER. 

Papillomata,  or  "villous  growths,"  are  among  the  more  frequent 
neoplasms  of  this  organ.  They  are  located  usually  upon  the  floor  and 
lower  portions  of  the  lining  membrane.  There  may  be  one  or  more. 
As  many  as  forty  of  these  neoplasms  have  been  removed  from  a  single 
bladder.  Microscopically,  they  are  composed  of  a  series  of  vascular 
loops  or  network,  covered  with  epithelia  of  the  same  iype  as  the  normal 
cells  of  the  mucous  membrane,  only  of  more  luxuriant  growth. 

The  symptoms  which  present  themselves  in  the  earlier  stages  of  the 
development  of  vesical  papilloma  are  obscure.  When  a  single  tumor 
exists,  and  is  not  of  rapid  growth,  the  bladder  may  become  tolerant  of 
its  presence.  Under  other  conditions,  symptoms  of  irritation,  frequent 
micturition,  and  tenesmus  may  be  x^resent.     If  the  growth  be  situated 


NEW   FORMATIONS  AND   TUMORS   OF  THE   BLADDER.     575 

near  the  outlet  of  the  bladder,  it  may  interfere  with  the  escape  of  urine. 
Hjematui'ia  is  of  frequent  occurrence  in  connection  with  this  variety  of 
tumor,  and  is  due  to  rupture  of  the  capillaries  from  ulceraticm  caused  by 
the  action  of  the  urine  upon  the  tnfts.  An  exacerbation  of  haemorrhage 
is  apt  to  follow  the  introduction  of  the  sound.  An  examination  of  the 
urine  may  demonstrate  the  presence  of  particles  of  the  papillomatous 
tissue.  If  a  sound  be  introduced  while  the  bladder  is  fairly  distended, 
so  as  to  efface  the  folds  into  which  the  mucous  membrane  is  thrown 
when  the  organ  is  contracted,  the  presence  of  the  tumor  may  be  recog- 
nized by  the  resistance  offered  as  the  convexity  of  the  sound  is  swept 
along  the  floor  and  sides  of  the  organ. 

The  treatment  is  to  open  into  the  bladder,  through  the  perinseum  as 
in  median  or  medio-lateral,  or  supra-pubic  lithotomy,  and  remove  the 
growths  with  the  wire  snare,  twist  them  off  with  the  forceps,  or  scrape 
them  off  with  Volkmann's  spoon,  guided  by  the  finger.  The  prognosis 
is  not  favorable,  owing  to  the  hpemorrhage  and  cystitis  caused  by  the 
operation,  and  the  danger  of  recurrence  owing  to  incomplete  removal. 

Flbiotna  and  myxoma  of  the  bladder  may  be  considered  as  next  in 
order  of  frequency.  They  belong  to  the  connective-tissue  type  of  new 
formations,  are  less  vascular,  and  of  slower  development,  although  at 
times  they  attain  considerable  size.  The  base  of  the  organ  is  the  usual 
location  of  the  tumor.  The  symxjtoms  are  about  the  same  as  those  in 
papilloma,  excepting  hsemorrhage.  The  diagnosis  will  depend  upon  the 
appreciation  of  the  growth  by  the  sound,  or  by  rectal  palpation  with 
the  sound  in  the  bladder.  If  the  character  of  the  lesion  can  not  be  ac- 
curately determined,  and  the  symptoms  of  irritation  are  present,  a  peri- 
neal exploratory  incision  may  be  made.  The  treatment  consists  in  the 
removal  of  the  mass  by  the  operation  just  given. 

Other  forms  of  benign  tumors  of  the  bladder  are  so  rare  as  scarcely 
to  deserve  mention.  Among  the  new  formations  myoma  is  occasionally 
found,  while  of  the  tumors  hydatid  cysts  are  sometimes  met  with.  These 
formations  are  amenable  to  the  same  rules  of  treatment  as  above  laid 
down. 

Of  the  malignant  diseases  of  this  organ,  sarcoma  is  extremely  rare  ; 
whUe  of  the  carcinoviata,  the  epithelial  variety  is  by  far  the  most  fre- 
quent. Scirrhus  may,  however,  originate  here.  The  symptoms  differ 
only  in  degree  in  the  malignant  as  compared  with  the  beuign  tumors  just 
described.  The  gradual  development  of  the  cachexia,  which  is  a  part  of 
cancer,  may  alone  lead  to  a  positive  diagnosis.  Exploration  with  the 
sound  and  rectal  examination  may  determine  the  suspicions  character  of 
the  disease  by  the  extent  of  the  inliltration  in  the  tissues  around  the 
bladder. 

Operative  interference  is  rarely  justifiable,  for  the  reason  that  the 
disease  is  almost  of  necessity  so  far  advanced  before  it  is  recognized 
that  a  thorough  removal  is  impossible. 

The  Urine — Qnantif?/. — The  average  quantity  of  urine  excreted  by 
the  kidneys  of  the  normal  adult  is  about  fifty-six  ounces  in  twenty-fmir 
hours.     This  quantity  varies  with  the  amount  of  fluids  ingested,  the  ac- 


576  A  TEXT-BOOK   ON   SURGERY. 

tivity  of  the  sweat-glands,  and  the  elimination  of  liquids  by  the  aliment- 
ary canal. 

It  is  of  an  amber-  or  straw-color,  which  is  due  to  the  presence  of 
indican  and  iirobiline.  Tlie  greater  the  quantity,  as  a  rule,  the  lighter 
the  color.  It  is  dark  in  proportion  to  the  intensity  of  the  destructive 
changes  in  tissue,  as  in  prolonged  exertion,  or  during  the  progi'ess  of 
fevers.  Carbolic  acid  and  bile  turn  the  urine  brown  or  greenisli-bhick, 
and  blood  (hjematuria)  gives  it  its  characteristic  tinge.  The  normal  odor 
of  urine  is  peculiar  to  itself.  An  artificial  aroma  is  easily  substituted  by 
the  ingestion  of  certain  foods  and  drinks,  as  gaultheria,  turpentine,  as- 
paragus, etc. 

Reaction. — Healthy  fresh  urine  is  acid  in  reaction,  changing  litmus 
from  blue  to  the  faintest  red  or  rose  color.  Acid  urine  will  at  times  l)e- 
come  alkaline  within  a  few  minutes  after  its  discharge.  The  ingestion 
of  alkaline  substances  in  vegetable  foods  gives  a  neutral  or  alkaline 
character  to  the  urine  passed  \Tithin  a  short  time  after  eating.  The  same 
is  true  of  the  alkaline  salts,  potash,  soda,  etc.  Urine,  alkaline  in  reac- 
tion as  it  leaves  the  urethra — the  alkalinity  not  due  to  food  or  medica- 
tion— is  an  indication  of  disease  of  the  bladder  or  pelvis  of  the  kidney. 

Specijic  GravUij. — The  specific  gravity  varies  in  the  normal  condition 
from  I'OOo  to  1'030.  Usually  the  increase  in  quantity  is  accompanied  by 
a  smaller  jiroportion  of  solids  and  a  consequent  lower  specific  gravity. 
This  is  not  the  case  in  diabetes,  where  the  quantity  is  abnormally  large, 
while  the  urinometer  may  register  as  high  as  1030-1040. 

It  becomes  a  matter  of  gi-eat  importance  to  determine  through  the 
chemical  and  microscopical  analysis  of  the  urine  the  condition  of  the 
organs  which  excrete  this  fluid  and  those  through  which  it  passes  in  its 
way  to  the  exterior.  Certain  conditions  of  the  kidneys,  as  in  Bright's 
disease,  render  the  prognosis  of  a  surgical  i:)rocedure  more  grave,  and 
may  justify  a  modification  of  the  treatment. 

Urea. — Ui-ea  is  the  result  of  destructive  tissue  metamorphosis.  It  is 
increased  by  the  ingestion  of  nitrogenized  food  and  by  excessive  muscu- 
lar exercise.  The  average  daily  quantity  excreted  by  the  urine  is  about 
four  hundred  and  fifty  grains,  which,  with  the  estimate  of  the  daily  urine 
at  fifty-six  ounces,  is  about  gr.  J  of  urea  to  3]  of  the  urine. 

Any  marked  diminution  of  this  proportion  indicates  failure  in  the 
elimination  of  the  products  of  waste  in  the  tissues  and  the  danger  of 
urcemia.  The  simplest  quantitative  test,  and  one  sufficiently  exact  for 
practical  purposes,  is  the  following :  To  make  it,  it  is  required  to  have 
Labarraque's  solution,  metallic  mercury,  a  saturated  solution  of  common 
salt,  and  a  graduated  glass  tube,  with  a  capacity  of  several  cubic  inches, 
and  of  a  caliber  not  so  large  but  that  the  open  end  can  be  readily  closed 
by  the  thumb. 

Fill  the  tube  one  third  full  of  mercury ;  on  top  of  this  pour  3  ss.  of 
urine,  fill  the  balance  of  the  tube  with  Labarraque's  solution  poured  in 
quickly,  and  as  quickly  close  the  end  of  the  tube  with  the  thumb.  In- 
vert the  tube,  carry  the  end  well  below  the  surface  of  the  saturated  solu- 
tion of  salt,  and  then  remove  the  thumb,  allowing  the  mercury  to  escape, 


THE  URINE— ALBFMEX— SUGAR.  577 

while  the  salt  water  rushes  in  to  take  its  place.  Allow  the  tube  to  re- 
main in  this  position  about  six  hours,  or  until  the  bubbling  entirely 
ceases.  The  volume  of  gas  which  rises  to  the  top  of  the  tube  represents 
the  proportion  of  urea  in  the  specimen  examined.  K  a  half- drachm  is 
used,  every  cubic  inch  of  displacement  of  the  liquid  within  the  tube  is 
equal  to  0'645  of  a  grain  of  urea.  Multiiilying  this  by  the  inches  or 
fractions  of  an  inch  of  gas  will  give  the  quantity  of  urea  in  3  ss.  of 
urine. 

Albumen. — Albumen  in  the  urine  of  one  in  health  is  exceedingly 
rare.  It  is  said  uot  to  indicate  disease  if  present  in  small  quantity  soon 
after  the  excessive  ingestion  of  albuminous  foods. 

In  isolated  cases  its  presence  is  ephemeral.  In  a  case  presented  be- 
fore the  New  York  Pathological  Society,  by  Prof.  Janeway,  albuminuria 
could  be  produced  at  will  by  increased  mental  activity.  In  a  condition 
of  repose  no  trace  was  discoverable. 

Albumen  is  always  present  in  urine  which  contains  pus,  independent 
of  any  affection  of  the  kidneys. 

It  may  be  recognized  by  the  tests  with  heat  and  nitric  acid.  To  em- 
ploy the  heat-test,  till  a  tube  half  full  of  urine,  to  which,  if  alkaline  or 
faintly  acid  in  reaction,  one  or  two  drops  of  acetic  acid  should  be  added. 
Hold  the  tube  so  that  the  flame  of  the  spirit-lamp  will  heat  the  upper 
inch  of  urine.  If,  just  before  the  boiling-point  is  reached,  a  cloudy 
white  film  pervades  the  heated  mass,  the  presence  of  albumen  is  demon- 
strated. 

The  nitric-acid  test  is  not  so  reliable  as  the  preceding.  When  albu- 
men is  thought  to  be  demonstrated  by  its  use,  the  heat-test  should  be 
applied  to  confirm  it.  Into  a  small  test-tube  drop  from  tu  x-xx  of  pure 
nitric  acid.  Hold  the  tube  slanting  and  allow  the  urine  from  a  glass 
pipette  to  run  gently  down  the  side  until  it  floats  upon  the  acid.  Albu- 
men is  indicated  by  a  white  or  cloudy  ring  formed  in  the  layer  of  urine 
immediately  in  contact  with  the  acid. 

Hu(jar. — The  iirine  of  diabetes  melUtus  has  a  high  specific  gravity,  is 
passed  in  great  quantity,  and  has  a  characteristic  sweet  odor.  This  form 
of  sugar  may  be  recognized  by  Trommefs  test,  in  which  an  oxide  of  co]i- 
per  is  produced  by  boiling  diabetic  urine  (grape-sugar)  with  a  solution 
of  potash  and  copper.  Fill  a  test-tube  for  one  inch  with  the  suspected 
urine,  and  add  one  or  two  drops  of  a  solution  of  sulphate  of  copper — 
just  enough  to  give  the  whole  a  pale-blue  tint.  Add  the  pota.sh  solution 
in  quantity  equal  to  one  half  the  urine.  When  sugar  is  present,  a  pale- 
blue  hydrated  oxide  of  copper  will  be  thrown  down  and  immediately  re- 
dissolved.  If  the  mixture  is  now  slowly  heated  to  near  the  boiling- 
point,  a  reddish-brown  suboxide  of  copper  wiU  be  precipitated. 

When  a  quantitative  analysis  is  desired,  the  fermentation-test  will  be 
found  simple  and  sufficiently  accurate  for  practical  use.  Fill  a  wide- 
mouthed  bottle  with  the  urine,  and  register  the  specific  gravity  at  the 
time.  Place  a  small  piece  of  yeast  in  the  urine,  and  set  it  aside  in  a  waim 
place  for  from  twelve  to  eighteen  hours  until  fermentation  has  occurred, 
and  again  take  the  specific  gravity.  The  difference  in  degrees  of  the  uri- 
37 


578  A  TEXT-BOOK   ON   SURGERY. 

nometer,  as  registered  before  and  after  fermentation,  will  represent  the 
nunilier  of  grains  of  sugar  in  the  ounce  of  urine. 

Pnx-  ((ltd  Bl(>(Kl-C(uj)iisdeK — EpUhcliit. — Pus-cells  in  the  urine  may 
come  from  an  intlamnuition  in  any  ijortion  of  the  urinary  tract,  from  the 
kidney  to  the  meatus,  or  from  the  communication  of  a  sinus  or  abscess 
with  the  urinary  apjjaratus.  Urine  containing  jtus  may  be  acid,  alka- 
line, or  neutral  in  reaction.  In  acid  urine  the  corpuscles  are  i)rominent 
and  easily  recognized ;  when  the  reaction  is  alkaline,  they  are  usually 
desti'oyed,  and  ajjpear  as  ro]iy  or  gelatinous  sti'ings,  more  resembling 
mucus  than  pus.  If  the  urine  is  examined  immediately  after  being 
passed,  a  few  corpuscles  may  be  recognized.  When  allowed  to  stand  for 
some  minutes,  the  pus-cells  collect  in  tlie  bottom  of  the  vessel.  Ex- 
amined with  the  microscope,  they  are  seen  to  be  spherical  and  faintly 
gninular.  On  account  of  the  absorjition  of  water,  they  are  swolh^n  and 
less  distinct  than  i)us-cells  from  a  lecent  abscess.  The  addition  of  acetic 
acid  renders  the  nuclei  more  distinct.  The  source  of  pus  found  in  the 
urine  may  frequently  be  determined  from  the  symjjtoms  present,  to- 
gether with  the  microscopical  appearances  of  the  urine.  If  with  the 
pus-corpuscles  flat,  large  epithelia  are  abundant,  the  inflammatory  pro- 
cess is  in  all  probability  situated  in  the  bladder  where  these  epithelia 
belong.  In  females  a  larger,  flat  epithelium  from  the  vagina  often  finds 
its  way  into  the  urine.  The  cells  from  the  vagina  are  more  often  disposed 
in  drifts  or  groui)s  than  the  bladder  epithelia.  Large  spherical  or  po- 
lygonal cells  may  come  from  the  kidney-tubules  or  the  male  urethra. 
They  are  about  twice  the  size  of  a  pus-corpuscle.  Whether  they  are 
derived  from  the  kidnej^  or  the  urethra  may  in  great  part  be  determined 
by  the  presence  or  absence  of  urethritis.  Conical  or  ham-shaped  cells 
may  come  from  the  pelvis  of  the  kidney,  prostate,  and  glandular  appa- 
ratus of  the  urethra.  They  are  usually  not  so  abundant  as  the  other 
varieties. 

IRenuduria. — Blood  in  the  urine  may  come  from  traumatic  or  idio- 
pathic haemorrhage  into  the  Malpighian  tufts  or  kidney-tubules ;  from 
the  pelvis  or  ureters  as  a  result  of  calciili  or  ulceration  ;  from  the  bladder 
as  a  result  of  instrumentation,  calculus,  wounds,  foreign  body,  neo- 
plasms, ulceration,  parasites,  or  the  hpemorrhagic  diathesis  ;  from  the 
prostate  or  accessory  organs  and  the  urethra. 

The  administration  of  certain  remedies  may  account  iov  the  appear- 
ance of  blood  in  the  urine.  Htematuria  occurs  at  times  as  a  symp- 
tom of  malarial  fever,  and,  in  women,  as  a  form  of  vicarious  men- 
struation. 

Blood  in  the  urine  may  lie  recognized  by  its  characteristic  coagula,  by 
the  red  or  reddish-brown  color  it  imparts  to  this  fluid,  the  presence  of 
the  corpuscles  under  the  microscope,  or  the  fibrinous  casts  of  the  tubules 
of  the  kidney  or  ureters.  In  rare  instances  the  blood-disks  are  entirely 
destroyed,  and  the  coloring-matter  set  free.  This  condition  is  apt  to 
occur  in  ammoniacal  urine. 

When  urine  containing  ])lood  is  boiled,  a  white  or  cloudy  coagulum 
is  formed,  its  density  depending  upon  the  quantity  of  blood  present. 


H.EMATURIA.  579 

If  bloody  urine  is  allowed  to  stand  without  being  agitated,  the  cor- 
puscles settle  to  the  bottom  of  the  vessel,  and  may  be  recognized  by  their 
red  or  amber  color.  Under  the  microscope  they  may  assume  different 
shajjes.  In  acid  urine  the  disks  retain  their  bi-concave  conformation  for 
a  long  time.  When  the  hsemorrhage  is  slight,  thej^  float  isolated  ;  if  pro- 
fuse, tliey  may  be  caught  in  coagula  or  collect  in  rouleaux.  If  the  re- 
action is  feebly  acid,  or  where  the  c<)ri:)uscles  are  submitted  for  a  consid- 
erable time  to  the  action  of  the  urine,  they  lose  their  bi-concave  shape, 
and  become  distended,  swollen,  and  spherical.  They  may  be  recognized 
from  pus-corpuscles  by  their  smaller  size,  transparency,  and  in  not  con- 
taining granular  bodies.  At  times  they  retain  their  flat  shape  and  appear 
with  serrated  edges. 

Blood-casts  usually  come  from  the  kidney-tubules,  and  are  composed 
of  fibrin  in  which  the  red  disks  are  entangled  in  varying  proportion. 
In  some,  large  clusters  or  groups  of  blood-corpuscles  are  seen,  with  an 
occasional  epithelial  cell  from  the  kidney  or  urinary  passages.  When 
the  disks  have  been  completely  destroyed,  as  in  the  decomposition  of 
the  coloring-matter  in  ammoniacal  urine,  and  the  organic  elements  of  the 
blood  are  not  recognizable  with  the  microscope,  the  spectroscope  may 
be  relied  upon  to  demonstrate  the  presence  of  the  coloring-mattei'. 

In  determining  the  source  of  blood  in  hsematuria  the  following  points 
should  be  considered  :  When  the  bleeding  is  urethral,  the  first  discharge 
of  ixrine  is  most  deeply  colored.  A  clot  of  blood  preceding  or  accom- 
panying the  discharge  of  urine  indicates  urethral  hsemorrhage.  In  males, 
if  spermatozoa  are  entangled  in  the  coagula,  the  suspicion  of  hjemor- 
rhage  from  the  vasa  deferentia  or  x>rostatic  apjiaratixs  is  entitled  to  con- 
sideration, although  the  fact  must  not  be  overlooked  that  these  elements 
may  mingle  in  the  urethra  with  blood  from  any  part  of  the  urinary 
passages. 

When  the  bleeding  is  from  the  pelvis  of  the  kidney,  pain  and  other 
symptoms  of  stone  or  pyelitis  will  often  precede  the  hjematuria.  Not 
infrequently,  however,  the  hajmorrhage  is,  next  to  the  presence  of  pus 
in  the  urine,  the  first  indication  of  pyelitis. 

In  haemorrhage  from  the  bladder  there  are  often  symptoms  of  cystitis 
which  will  point  directly  to  this  organ  as  the  source  of  tlie  bleeding. 
In  diiferentiating  the  origin  of  blood  from  the  kidneys,  ureters,  and  the 
bladder,  the  method  of  Thompson  and  Van  Buren  may  be  resorted 
to  with  success.  Introduce  a  soft  catheter  just  within  the  neck  of  the 
bladder,  draw  off  the  contained  urine,  and  wash  out  the  organ  with 
clean  water.  If,  during  the  irrigation,  the  water  which  flows  away 
contains  blood,  the  hfemorrhage  is  from  the  bladder-walls.  If  it  flows 
away  clear,  then  empty  the  bladder,  place  the  finger  over  the  end  of  the 
catheter,  allow  it  to  remain  introduced,  and  wait  until  a  small  quantity 
of  urine  has  accumulated.  This  is  drawn  off,  and,  if  it  is  bloody,  and 
if  the  clear  water  now  thrown  in  comes  out  unstained,  the  inference  is 
fair  that  the  bleeding  is  from  the  ureters  or  beyond. 

Hjpmorrhage  from  the  uretlira  is  rare  except  from  violence,  the  lodg- 
ment of  calculi,  or  from  ulceration. 


580  A  TEXT-BOOK  ON  SURGERY. 

ILcniatiiria  clue  to  parasitic  lodgmont  in  tlie  walls  of  tlie  bladder  is 
exceedingly  rare  in  this  country.  In  1883  a  young  man  of  white  parents 
— a  native  of  Natal,  Africa— cauie  Tinder  my  care  on  account  of  chronic 
hsematuria.  He  was  at  this  time  twenty-six  years  of  age,  and  had  had 
bloody  urine  at  intervals  for  thirteen  years.  His  health  was  not  seriously 
impaired.  The  urine  was  faintly  acid  ;  specific  gravity  l-()20,  with  oidy  a 
trace  of  albumen,  which  was  readily  accounted  for  by  the  slight  amount 
of  blood.  About  the  middle  and  toward  the  last  stage  of  the  act  of  mic- 
turition, a  few  strings  of  clotted  blood  were  dis- 
charged. Placing  these  under  the  microscope,  I 
discovered  a  number  of  bodies  (Fig.  580)  shaped 
much  like  a  watermelon-seed,  except  that  the  small 
end  was  more  pointed.  These  were  evidently  the 
eggs  of  the  parasite  known  as  Bllharzia  hivmato- 
hi(t,  the  hsematuria  resulting  from  the  rupture  of 
^'"zirhmni'itobia"'  r'cn'-  cai^illaries  caused  by  the  ]iresence  of  nests  of  these 
Dated  Hood -disks.    3,     ^va  in  the  mucous  membrane  of  the  bladder.     This 

ipithelmm.   4,  rus-cell. 

(From  the  author's  case.)  disease  IS  frequent  in  Africa  and  Asia,  but  almost 
unknown  in  North  America.  The  l)ody  of  the  male 
parasite  is  about  four  lines  in  length,  thread-like,  and  ilattened  ante- 
riorly (Aitken)  ;  the  female  a  little  shorter  and  more  delicate.  They 
inhabit  by  preference  the  portal  vein  and  the  walls  of  the  bladder.  In 
treating  my  patient  I  saturated  him  with  large  doses  of  santonin  for  a 
week,  and  injected  the  bladder  daily  with  alcohol,  beginning  with  a 
l-to-20  solution,  and  increasing  it  to  the  extreme  degree  of  tolerance  V)y 
the  bladder.  The  patient  improved  in  every  respect,  but  the  hjcmatu- 
ria  was  not  entu'ely  arrested  when  he  returned  to  Africa  in  November, 
1883,  since  which  time  I  have  not  heard  from  him. 

The  parent  distoma  is  killed  by  high  febrile  movement,  and  with  its 
death  the  hajmaturia  ceases. 

The  treatment  of  h?ematuria  must  be  directed  to  the  disease  of  which 
it  is  a  symptom.  The  patient  should  be  required  to  remain  in  the  re- 
cumbent posture.  The  administration  of  the  fluid  extract  of  ergot,  3j-ij, 
is  highly  recommended  without  regard  to  the  source  of  the  bleeding. 
Large  doses  of  citrate  of  potash  will  prove  beneficial  in  rendering  the 
urine  less  irritating.  Opium  is  advisable,  not  only  on  account  of  the 
relief  from  pain  it  affords,  but  because  it  secures  comi)lete  quiet,  which 
is  essential,  and  prevents  the  too  frequent  evacuation  of  the  bladder. 

When  the  ha?morrhage  is  from  this  organ,  and  does  not  yield  to  the 
measures  above  given,  the  injection  of  cold  or  hot  water,  or  of  astringent 
solutions,  may  be  employed.  If  villous  growths  are  present,  they  should 
be  removed  by  cystotomy. 

Stone  in  the  Bladder. 

Urinary  calculi  may  form  in  any  portion  of  the  kidney,  in  the  pelvis 
or  ureters,  in  the  bladder  or  urethra.  They  are  concretions  of  the  va- 
rious inorganic  substances  which  are  common  to  the  urine.     Organic 


STONE   IN  THE   BLADDER.  581 

particles,  such  as  epithelia,  mucus,  and  various  inflammatory  products, 
often  enter  into  the  formation  of  calculi.  When  an  aggregation  of  the 
urinary  salts  occurs  within  the  kidney-tubules,  the  probabilities  are  that 
the  stone  so  formed  will  remain  imprisoned  in  this  organ  (renal  calculus) 
until  removed  by  ulceration  or  operation.  Forming  in  the  larger  straight 
tubes  of  the  pyramids,  a  urinary  concretion  may,  while  yet  minute,  es- 
cape into  the  calix  and  pelvis,  and  pass  down  the  ureter  into  the  blad- 
der, or  remain  lodged  in  the  pelvis  or  excretory  duct. 

It  is,  moreover,  probable  that  the  majority  of  calculi  found  in  the 
bladder,  or  passed  by  the  urethra,  originate  as  concretions  in  the  straight 
tubes,  calices,  or  pelves  of  the  kidneys,  whence  they  drift  outward  to 
the  bladder,  and  there  by  continued  accretion  become  large  enough  to 
attract  attention,  even  if  the  transit  along  the  ureter  was  unnoticed. 
Undoubtedly  a  fair  proportion  of  vesical  calculi  are  formed  in  this  organ 
proper,  and  the  greater  number  of  these  may  be  grouped  in  the  class  of 
calculi  which  form  around  nuclei  composed  of  foreign  substances,  or 
animal  matter,  such  as  epithelia,  inflammatory  products,  etc.  Conversely, 
it  is  admitted  that  animal  matter  may  form  the  nucleus  of  a  kidney  or 
pelvic  concretion,  while  a  bladder  calculus  may  also  be  formed  by  accre- 
tion of  the  purely  inorganic  elements  of  the  urine. 

A  calculus  is  rarely  of  uniform  composition,  more  frequently  com- 
bining two  or  more  inorganic  as  well  as  organic  elements  in  its  forma- 
tion. In  the  nomenclature  it  is  the  practice  to  give  to  the  stone  the  name 
of  the  preponderating  element. 

That  most  commonly  observed  is  comjiosed  principally  of  tirlc  acid 
and  the  urates.  These  stones  are  of  fair  consistency,  yellowish  or 
light-brown  in  color,  not  very  smooth  when  single,  yet  not  so  rough 
as  oxalate-of-lirae  concretions.  They  may  attain  a  diameter  of  two  or 
three  inches.  As  a  rule,  they  form  in  urine  which  is  distinctly  acid  in 
reaction. 

The  mulberry  or  oxalate-oflime  calculus  is  next  in  order  of  fre- 
quency, and  relatively  more  so  in  childi-en  than  in  adults.  They  may 
exist  in  all  sizes,  and  vary  greatly  in  color.  The  smaller  concretions  are 
light  in  color  and  fairly  smootli ;  the  larger  are  exceedingly  rough,  with 
jagged  edges,  and  are  dark-brown  in  color,  in  rare  instances  white. 
Oxalate-of-lime  calculi  usually  commence  in  the  kidney,  and  pass  as 
small  particles  to  the  bladder.  The  most  severe  forms  of  "renal  colic" 
are  due  to  the  slow  and  painful  passage  of  these  rougher  concretions 
along  the  ureters. 

PhospJiatie  calculi  come  next  in  order  of  frequency,  and  are  divis- 
ible into  three  classes  :  the  aiinnoiiio-mafinesian  and  phospliate-of-Jime 
{fusible)  calculus,  neutral  phosphate  of  lime,  and  ammonio-magiiesian 
calculus. 

Fusible  calculi  are  more  often  met  with  than  the  other  two  forms  of 
phosphatic  concretions.  They  are  g'ray  or  white  in  color,  readily  friable, 
iind  light.  The  hardness  is  proportit)nate  to  the  lime  phosphate  present. 
They  attain  large  size,  and  conform  themselves  to  the  shape  of  the 
bladder. 


582  A  TEXT-BOOK  ON   SURGERY. 

The  neutral  phosphate-of-I i me  calculus  is  rare.  It  may  furni  in  the 
kidney,  though  it  originates  chiefly  in  the  bladder.  All  the  phosphatic 
calculi  are  chiefly  vesical  ia  origin,  being  found  with  amniDiiiacal  urine, 
which  is  present  with  chronic  vesical  catarrh.  Tlie  aminunlo-mugneslan 
phosphatic  concretion  is  equally  rare,  and  differs  very  slightly  in  its 
chemical  and  physical  characters  from  that  just  described. 

Other  and  still  rarer  forms  of  urinary  concretions  are  the  following : 

Cysthi. — This  variety  is  usually  smooth,  occasi(mally  corrugated, 
yellow  in  color  when  fresh,  inclining  to  a  greenish  hue  when  long 
removed.  They  break  readily,  do  not  show  a  marked  concentric  arrange- 
ment, and  are  somewhat  greasy  to  the  feel. 

Xanthic  or  uric-oxide  calculi  have  only  been  reported  in  two  or  three 
instances.  They  are  of  concentric  formation,  smooth  and  gi-easy  to  the 
feel,  and  vary  in  color  from  gray  to  brown. 

Qarhonate-of-llme  calculi  are  usually  inultiple,  and  are  light-gray  in 
color  and  chalky  in  consistence. 

Orf/(tnlc  calculi,  consisting  of  epithelia,  blood,  etc.,  are  not  infrequent 
as  nuclei  for  other  varieties,  but  exceedingly  rare  as  independent  forms. 

Stone  in  the  bladder  is  a  misfortune  that  may  befall  every  age  and 
condition  of  human  life,  from  the  foetus  in  t/fero,  to  the  old  and  decrepit. 
The  period  of  greatest  exemption  is  from  twenty  to  fifty  years  of  age. 
It  is  comparatively  frequent  in  children,  and  here  must  be  of  renal  origin 
and  due  to  the  excess  of  inorganic  elements  in  the  urine,  since  obstruc- 
tion and  inflammatory  diseases  of  the  urinary  tract  rarely  exist  at  this 
age.  After  fifty,  when  prostatic,  cystic,  and  urethral  obstruction  are  more 
frequently  met  with,  the  formation  of  calculi,  vesical  in  origin,  is  more 
common.  As  to  sex,  stone  is  more  frequent  in  males.  It  was  formerly 
argued  that  there  was  no  difference  in  the  frequency  of  stone  in  the 
sexes,  but  that  the  short  and  dilatable  urethra  of  the  female  allowed 
a  ready  escape  to  the  concretion  before  it  became  sufficiently  large  to 
produce  any  organic  disturbance.  When,  regardless  of  the  statisti- 
cal evidence  which  shows  that  the  number  of  deaths  in  males  from 
urinary  calculus  is  ten  times  greater  than  in  females,  we  consider  that 
one  of  the  most  frequent  cau.ses  of  stone  is  the  gonty  diathesis,  and 
that  gout  is  more  frequent  in  men  ;  and,  again,  that  prostatic  and 
urethral  obstruction  is  peculiar  to  this  sex — it  must  be  conceded  that 
the  conditions  for  the  formation  of  calculi  are  more  frequently  present 
in  males. 

In  the  (Btiology  of  stone  in  the  bladder  two  great  factors  are  recog- 
nized :  The  one  includes  all  conditions  of  the  economy  which  favor  pre- 
cipitation of  the  inorganic  elements  of  the  urine ;  the  second  all  ob- 
structive and  inflammatory  lesions  which  produce  decomposititm  of  the 
urine  in  the  bladder,  the  detachment  of  epithelia,  and  the  accumulation 
of  other  organic  elements  which  serve  as  nuclei  around  which  the  salts 
of  the  urine  are  congregated. 

In  the  first  category  are  hereditary  tendencies,  such  as  gout  and  I'heu- 
matism.  Certain  conditions  of  malnutrition  undoulitedly  lead  to  a  pre- 
cipitation of  the  urinary  salts,  for  children  poorly  fed  and  cared  for  are 


STONE  IX  THE  BLADDER.  583 

much  more  apt  to  suffer  from  calculus  than  those  which  are  well  fed  and 
comfortably  clothed  and  sheltered. 

It  can  scarcely  be  doubted  that  residence  exercises  a  causative  influ- 
ence upon  the  formation  of  calculus.  In  the  United  States,  ]yorthern 
Alabama,  Tennessee,  and  Kentucky  afford  a  large  number  of  this  class 
of  cases,  while  in  New  York  and  the  New  England  States  stone  in  the 
bladder  is  exceedingly  rare. 

In  the  group  of  local  causes  may  be  classed  all  cystic  diseases  in 
which  the  products  of  inflammation  collect  in  the  bladder  and  fonn 
nuclei,  around  which  conci'etions  occur ;  prostatic  enlargement  induc- 
ing retention,  cystitis,  and  decomposition  of  urine ;  stricture,  and  all 
obstructive  and  inflammatory  lesions  of  the  iirethra  which  may  involve 
or  affect  the  integrity  of  the  bladder ;  the  presence  of  any  foreign  matter 
in  the  bladder,  or  paralysis  of  the  bladder  from  any  cause. 

The  iiymptoms  and  Diagnosis. — It  may  be  stated  at  once  that,  how- 
ever much  has  been  and  may  be  said  of  the  value  of  the  various  symptoms 
of  stone,  the  diagnosis  rests  upon  one  simple  expedient,  the  introduction 
of  a  metallic  instrument  into  the  bladder,  and  in  contact  with  the  stone. 
For  this  purpose  the  ordinary  steel  sound  is  usually  sufficient.  The 
bladder  should  be  allowed  to  contain  about  half  a  pint  of  fluid,  and 
when  the  instrument  is  introduced  it  should  be  manipulated  so  that  the 
convexity  of  the  curve  will  glide  over  the  floor  of  the  bladder  back  and 
forth  from  the  neck  to  the  posterior  wall  of  the  organ,  at  the  same  time 
depressing  the  bladder  toward  the  rectum.  By  this  manoeuvre  the  stone 
will  be  induced  to  gravitate  to  the  deeper  portions  in  contact  with  the 
instrument,  or  so  close  to  it  that  a  sharp,  quick  turn  to  right  or  left  will 
bring  the  calculus  and  metal  into  appreciable  contact.  In  certain  cases 
of  prostatic  hypertrophy  the  calculus  may  remain  concealed  immediately 
behind  the  enlarged  organ,  and  in  such  a  position  that  the  sound  can  not 
be  brought  in  contact  with  it.  Under  such  conditions  Thompson's  searcher 
(Fig.  581)  will  be  found  useful.     The  objection  to  this  instrument  is  the 


Fig.  581. — Thompson's  searcher. 


difficulty  of  its  introduction  from  the  abrupt  nature  of  the  curve  near  the 
tip.  When  once  introduced  its  value  is  readily  appreciated.  Turning 
its  point  downward  and  moving  as  if  to  withdraw  it,  there  is  no  jiortion 
of  the  floor  that  it  will  not  thoroughly  search. 

When  a  stone  can  not  be  appreciated  with  a  full  or  half-tilled  bladder 
it  may  be  felt  if  this  organ  is  completely  emptied.  Not  only  is  the  cal- 
culus driven  toward  the  neck  of  the  bladder  when  it  is  emptied  of  urine, 
but  the  hardness  and  weight  are  more  readily  appreciated,  since  it  is 
held  in  the  grasp  of  the  organ,  and  can  not  slip  away  when  the  sound 
touches  it.  In  some  forms  of  vesical  calculus  the  stone  becomes  partially 
or  completely  encysted  in  some  portion  of  the  bladder-wall.  The  calculus 
may  drop  into  an  abnormal  pouch  in  the  bladder  ;  it  may  sink  by  a  pro- 


584  A  TEXT-BOOK   OX   SURGERY. 

cess  of  ulceration  into  the  walls,  and  be  partiallj'  or  completely  snr- 
rounded  by  a  newly  fonned  inflammatory  tissiie,  or  it  may  have  been 
lodfred  in  the  ureter  near  its  termination. 

Again,  a  stone  may  be  caught  in  the  upper  portion  of  the  bladder 
without  being  sacculated.  In  sounding  for  stone  in  adults,  ether  narcosis 
is  not  always  required,  especially  where  there  are  no  symptoms  of  severe 
cystitis  and  tenesmus.  In  children  an  anaesthetic  should  always  be  em- 
ployed. When  the  calculus  can  not  be  felt  after  careful  search,  it  is  at 
times  a  successful  expedient  to  introduce  the  finger  into  the  rectum  and 
make  upward  pressure  upon  the  base  of  the  bladder,  and  firm  ])rpssure 
downward  ui)on  the  abdomen,  just  above  the  symphysis  pubis. 

Vesical  calculus  may  be  suspected  in  a  patient  who  has  had  renal 
colic,  or  has  passed  by  the  urethra  particles  of  gravel,  and  afterward 
develops  a  cystitis.  Not  infrecpiently,  however,  a  concretion  goes  fi'oni 
the  kidney  into  the  bladder  without  attracting  the  attention  of  the 
patient.  If  it  lodges  here,  and  increases  slowly  in  size,  it  may  remain 
for  mcmths  or  years  without  giving  any  symptoms  of  cystitis,  or  mark('(l 
annoyance.  Usually,  however,  when  a  stone  is  present,  and  is  so  light 
and  smooth  that  it  does  not  affect  the  mucous  membrane  of  the  bladder, 
it  attracts  attention  by  mechanical  interference  with  the  escape  of  urine, 
dropping  at  times  into  the  orifice  of  the  urethra,  and  suddenly  shutting 
off  the  flow  during  micturition. 

When  a  stone,  by  reason  of  its  size,  weight,  and  roughness,  begins  to 
cause  cystitis,  frequent  micturition  is  a  prominent  symptom.  A  burning 
or  smarting  pain,  referred  to  the  end  of  the  penis,  is  a  frequent  symptom 
in  this,  as  in  idiopathic  inflammation  of  this  organ.  At  times  the  i)ain 
is  referred  to  the  scrotum,  penis,  uterus,  and  other  organs,  or  along  the 
nerve-tracts  in  the  lower  extremities.  In  any  jolting  movement,  as  in 
riding  on  horseback,  or  in  vehicles  without  springs,  or  in  walking  about, 
the  pain  is  increased.  Tenesmus  is  often  violent  toward  the  end  of  urina- 
tion, when  the  stone  is  grasped  by  the  contracting  bladder.  The  urine 
almost  always  contains  pus,  and  blood  is  frequently  present.  Ha>matuiia, 
with  calculus,  occurs  chiefly  during  the  waking  hours,  when  the  patient 
is  moving  about.  It  is  more  apt  to  be  met  with  in  oxalate-of-lime  calculi 
than  in  the  other  varieties.  In  the  rare  instances  in  which  st(me  exists 
with  villous  growths  of  the  bladder,  h;emorrhage  is  often  excessive. 
When  a  calculus  is  of  large  size,  it  may  by  pressure  produce  pain  and 
symptoms  f>f  disturbance  in  other  organs,  as  the  vagina,  uterus,  or  lec- 
tum.  The  size  and  character  of  a  stone  in  the  bladder  may,  in  a  measure, 
be  determined  by  exploration  with  the  sound,  as  well  as  by  palpation. 

A  large  stone  is  usually  felt  as  soon  as  the  sound  enters  the  neck  of 
the  bladder.  The  sense  of  resistance  is  greater,  and  a  fair  idea  of  its 
proportions  may  be  made  out  by  passing  the  metallic  sound  along  its 
surfaces.  A  small  stone  is  often  with  difficulty  recognized.  Pressure 
above  the  sj-mphysis  pubis,  and  intra-vaginal  or  rectal  exi^loration,  are 
not  without  value  in  estimating  the  size  of  a  calculus.  If  the  click  of  the 
sound  is  sharp  and  clear,  and  if  the  surface  is  rough  and  grating  to  the 
sense  of  touch  conveyed  along  the  instrument,  an  oxalate-of-iime  stone 


STONE   IN   THE   BLADDER.  585 

may  be  suspected,  and,  if  the  patient  is  a  child,  the  suspicion  is  strength- 
ened. Hfematuria,  and  all  the  symptoms  of  cystitis,  are,  as  a  rule,  in- 
creased with  this  form  of  calculus.  In  patients  A\ith  the  gonty  or  rheu- 
matic diathesis,  uric-acid  stone  is  the  rule.  The  acidity  of  the  urine  in 
a  measure  excludes  phosphatic  calculus.  In  the  exceptional  instances  in 
which  a  portion  of  the  surface  of  the  bladder  has  become  incrusted  with 
the  inorganic  elements  of  the  urine,  this  condition  may  be  detennined  by 
the  immobility  of  the  concretion  when  the  sound  is  brought  in  contact 
with  it.  The  absence  of  a  spherical  calculus  can  be  determined  by  digital 
exploration  through  the  rectum  or  vagina,  coraljined  with  pressure  from 
above  the  symj^hysis  pubis. 

Treatment  and  Prognosis. — The  attempts  to  dissolve  vesical  calculi 
by  the  administration  of  remedies  by  the  mouth,  or  by  solutions  thrown 
into  the  bladder,  have  not  met  with  encouraging  success.  While  there 
is  little  doubt  that  the  correction  of  a  dyscrasia  which  is  favorable  to  the 
fomiation  of  stone  may  prevent  or  retard  the  further  growth  of  an  ex- 
isting concretion,  there  is  no  evidence  to  prove  that  a  stone  in  the  blad- 
der was  ever  removed  by  this  plan  of  treatment. 

The  proper  treatment  of  stone  in  the  bladder  may  be  divided  into  the 
curative  and  palliative.  To  the  former  belong  the  operations  of  lithot- 
omy and  lithotrity ;  to  the  latter  are  systematic  medication  and  hy- 
giene, together  with  the  employment  of  all  local  means  calculated  to 
relieve  pain  and  prolong  life.  In  deterndning  ui)on  the  proper  method 
to  be  adopted,  the  following  points  should  be  duly  considered  : 

In  male  patients  under  the  age  of  seventeen  the  cutting  operation  is 
preferable,  for  the  reas(ms  that  (1)  the  caliber  of  the  urethra  is  usually 
too  small  to  admit  of  the  instrumentation  necessary  to  lithotrity  ;  (2)  the 
mortality  rate  after  lithotomy  in  this  class  of  patients  is  very  low — about 
5  per  cent.  After  this  period,  as  between  lithotomy  and  lithotrity,  the 
former  operation  is  demanded  (1)  in  all  cases  of  stricture  of  the  urethra, 
where  the  caliber  of  this  tube  is  narrowed  to  such  an  extent  that  the  re- 
peated introduction  of  the  lithotrite  and  washing-apparatus  is  difficult  or 
impossible;  (2)  in  prostatic  disease,  with  hypertrophy  to  such  an  extent 
that  it  offers  an  impediment  to  the  introduction  of  the  instruments,  and 
renders  the  seizure  of  the  stone  or  fragments  difficult  of  accomplishment ; 
(3)  when  the  stone  is  more  than  one  inch  in  diameter ;  (-1)  when  it  is  so 
hard  (oxalate  of  lime)  that  it  can  not  be  crushed  by  the  employment  of  a 
reasonable  degree  of  force  ;  (5)  when  chronic  cystitis  and  vesical  intoler- 
ance exist ;  (6)  in  a  jjatient  suffering  from  any  foi-m  of  nephritis. 

Lithotrity. — If  the  symptoms  are  not  so  distressing  as  to  demand 
immediate  interference,  from  ten  days  to  two  weeks  should  be  devoted 
to  the  careful  preparation  of  the  patient.  It  is  not  only  important  to 
improve  the  genera,l  condition,  but  also  to  accustom  the  urethi-a  to  the 
introduction  of  the  sound. 

The  instruments  rec^uired  are  the  lithotrite  and  an  apparatns  for  wash- 
ing out  the  detritus. 

Of  the  various  crushing-instruments  which  have  been  introduced,  that 
of  Sir  Henry  Thompson  is  to  be  jiref erred  (.Figs.  582-585).     It  is  com- 


586 


A  TEXT-BOOK   OX  SURGERY. 


niendable  for  its  lightness,  strength,   and   smooth  action.      With  the 
heavier  instruments  the  sense  of  touch  is  not  so  delicate  and  acute.     The 

lighter  lithotrite  is  strong  enough 
to  crush  any  calculus  which  may 
be  safely  removed  by  this  opera- 
tion. Moreover,  it  Is  especially 
to  be  commended  for  the  fenes- 
trated jaw  in  the  female  blade 
{Fig.  582),  which  allows  the  male 
blade  to  pass  entirely  through, 
and  thus  avoids  the  danger  of 
choking  and  fouling.  It  consists 
of  a  male  blade  (Fig.  583),  or  sliding  rod,  which  fits  into  a  fixed  or  female 
blade  (Fig.  584j,  which  is  deeply  hollowed  out  for  its  reception. 


Fig.  582. 


CTiEMA/an-co. 
-Fenestrated  jaws  of  Thompson's  lithotrite. 


i. 


.TIEWftNH  &.C3 
Fig.  583.— Male  blade  of  Thompson's  lithotrite. 


0.  7l::MAf\JiM  Si  CtJ 

Fin.  584. — Female  blade  of  Thompson's  lithotrite, 


The  seizing  and  crushing  action  of  the  lithotrite  is  double.  '\\'hen  tlie 
male  blade  is  carried  through  the  hollow  handle  into  the  slot  in  the  female 
blade,  a  simple  and  rapid  to-and-fro  movement  can  be  executed  by  push- 
ing or  pulling  on  the  male  blade  with  the  right  hand,  AvhOe  the  left 


6-.  TIEMANN.  CO.N.  k" 

Fio.  585.— Thompson's  lithotrite  adjusted. 


Steadies  the  female  blade,  to  which  the  handle  is  attached.  This  move- 
ment can  be  made  very  effective  in  seizing  the  stone  and  in  crushing  the 
smaller  fragments  without  taking  the  extra  time  in  sliding  the  catch 
which  throws  on  the  screw-motion  of  the  instrument. 

When,  however,  a  stone  is  caught  in  its  grasp  by  the  sliding  move- 
ment just  described,  and  is  so  solid  and  resisting  that  a  sufiicient  and  safe 
crushing  force  can  not  be  employed,  the  catch  on  the  top  of  the  handle  is 
slipped  upward.  The  sliding  movement  is  now  impossible,  and  the  more 
powerful  screw-motion  substituted.  By  turning  the  wheel  at  the  end  of 
the  male  blade  to  the  right,  the  stone  can  be  felt  to  give  way  under  the 
crushing  force. 

In  the  removal  of  vesical  calculi  by  this  operation  two  procedures  are 
recognized,  viz.,  complete  and  incomplete  lithotrity. 

In  the  former,  or  Bigelow's  method,  ether  narcosis  is  required  :  the 
stone  is  entirely  crushed,  and  the  fragments  washed  out  at  a  single 


STONE  EST  THE   BLADDER— LITHOTRITY.  587 

operation.  In  the  latter,  anfesthesia  is  not  employed  ;  the  calculus  is 
only  partially  comminuted,  and  the  fragments  are  left  to  pass  oil  with 
the  urine. 

Complete  lithotrity  has  almost  entirely  superseded  the  older  operation. 
It  is  preferable  in  all  cases  where  the  condition  of  the  patient  justilies  the 
risk  of  shock  from  a  capital  operation  under  ether  narcosis. 

Operation. — Tlie  patient,  being  narcotized,  is  placed  upon  the  operat- 
ing-table, in  the  dorsal  decubitus,  with  the  pelvis  raised  about  half  a  foot, 
by  pillows  placed  under  the  sacrum.  If  the  bladder  has  not  been  emptied 
just  before  the  operation,  the  urine  is  now  drawn  off  and  about  one  pint 
of  tepid  water  injected,  thus  distending  this  organ  and  rendering  the 
mucous  membrane  less  liable  to  injury  from  being  picked  iip  by  the  in- 
strument. The  litbotrite,  having  been  properly  warmed,  oiled,  and  tested 
as  to  its  working  capacity  and  strength,  is  now  prepared  for  introduction, 
by  sliding  the  male  blade  completely  down  until  its  tip  passes  into  the 
fenestra  of  the  female  blade.  As  the  convexity  of  the  male  blade  is 
serrated,  great  care  must  be  taken  not  to  push  the  rough  surface  beyond 
the  level  of  the  female  blade,  since  the  introduction  of  the  instrument, 
improperly  adjusted,  would  do  iinnecessary  violence  to  the  floor  of  the 
urethra. 

A  right-handed  operator  should  stand  at  the  patient's  right  side.  The 
instrument  is  locked  and  carried  into  the  bladder  by  the  same  manoeuvres 
as  given  for  the  introduction  of  the  sound  or  metal  catheter.  "When  the 
beak  is  well  into  the  bladder,  it  is  earned  along  the  floor,  with  the  tip 
pointing  upward,  until  it  meets  with  the  resistance  of  the  posterior  wall 
of  the  bladder,  when  it  should  be  slightly  withdra^^Ti.  The  handle  should 
now  be  elevated,  in  order  to  depress  the  floor  of  the  bladder  with  the  con- 
vexity of  the  curve.  Held  firmly  in  this  position,  the  lithotrite  is  opened 
by  withdrawing  the  male  blade  about  two  inches.  The  operator  should 
now  strike  the  handle  of  the  instrument  with  the  knuckles  or  hand, 
hard  enough  to  carry  the  concussion  to  the  bladder,  in  order  to  dislodge 
the  calciilus  and  allow  it  to  fall  into  the  lowest  portion  of  the  organ,  and 
within  the  grasp  of  the  lithotrite,  which  is  now  closed  by  pushing  the 
male  blade  down.  If  the  stone  is  seized,  it  will  be  made  evident  by  the 
failure  to  close  the  blades,  and,  when  caught,  it  should  be  firmly  held, 
the  screw-movement  adjusted,  and  the  wheel  rotated  slowly.  Having 
thus  secured  the  stone,  the  instrument  should  be  moved  to  and  fro,  in 
order  to  assure  the  operator  that  the  wall  of  the  bladder  is  not  canght. 
In  crushing  a  calculus,  the  rapidity  with  which  it  is  done  should  be  de- 
termined by  the  sense  of  resistance  experienced.  It  is  not  safe  to  employ 
force  sufficient  to  spring  the  blades.  A  stone  which  can  be  safely  crushed 
will  yield  perceptibly  under  a  few  turns  of  the  screw.  Phosphatic  stone 
can  often  be  rapidly  comtniniited  without  adjusting  the  screw.  Uric-acid 
calculi  require  more  power,  while  the  oxalate-of-lime  at  times  can  not  be 
crushed  at  all. 

If  the  mana?uvre  above  described  fails  after  being  several  times  care- 
fully repeated,  search  must  be  made  in  other  quarters.  Holding  the 
instrument  beak  upward,  the  convexity  still  upon  the  floor  of  the  blad- 


588 


A  TEXT-BOOK  ON  SURGERY. 


1 


*»K 


STOHLMAg^^!;/ 


'TARRF  &IOi 


der,  separate  the  bhules,  turn  the  shal't  liali'  over  to  tlie  riglit,  and  then 
close  the  blades.  If  the  stone  is  seized,  hold  it  steady,  adjust  the  screw- 
motion,  tighten  the  grip  by  a  slight  turn  of  the  wheel,  and  carry  the 
instrument  back  to  the  middle  line  with  the  beak  jjointing  upward.  If 
it  does  not  move  freely,  the  indication  is  that  the  bladder  has  been  picked 
up,  and  of  course  the  blades  must  be  separated  and  another  effort  made. 
With  the  instrument  shown  there  is  little  danger  of  this  accident.  The 
same  manaHivre  may  be  tried  on  the  ox)posite  side.  If  there  is  prostatic 
enlargement,  it  may  be  necessary  to  turn  the  beak  do\\aiward  into  the 
pocket  on  the  floor  of  the  bladder.  If,  after  a  half-hour's  seai-ch,  the 
seizure  has  not  been  effected,  the  operation  should  be  discontinued. 

Wlien  the  stone  has  been  seized  and  broken  once,  the  same  manoeuvres 
should  be  carefully  yet  rapidly  repeated  until  no  large  pieces  remain. 
It  will  usually  be  found  easy  to  crush  the  smaller  jjieces  by  the  sliding 

movement  alone.  The  instrument  should 
now  be  closed  until  the  blades  have  the 
same  relatitm  as  when  introduced,  and  then 
withdrawn.  The  evacuator  consists  of  a 
rubber  bulb  capable  of  holding  about  one 
|)int.  At  the  upper  end  is  a  funnel  and 
stop-cock  for  filling  and  closing  the  appa- 
ratus. Below  is  attached  a  glass  globe,  in 
which  the  particles  of  stone  gravitate  as 
fast  as  they  are  drawn  into  the  evacuator. 
Between  this  and  the  rubber  bulb  is  a  sec- 
(md  stop-cock,  and  a  place  for  attaching  the 
catheter.  It  is  advisable  to  insert  a  piece 
of  rubber  tubing,  about  five  inches  in  length, 
between  the  catheter  and  the  evacuator,  in 
order  to  prevent  the  jarring  motion  impart- 
ed to  the  bulb  from  being  conveyed  to  the 
instrument  in  the  bladder.  The  catheters 
(Fig.  580)  are  of  different  sizes  and  shapes, 
ranging  from  No.  14  to  No.  25,  U.  S.  The 
evacuation  is  much  more  rapid  with  the 
larger  instmxments.  However,  the  urethra 
should  not  be  over-distended.  In  general, 
the  catheters  which  are  only  slightly  curved  near  the  tip,  with  the  eye 
at  the  extremity,  are  preferable.  In  filling  the  bulb,  in  order  to  exclude 
the  air,  the  glass  ball  is  first  detached,  filled  with  clean  warm  water, 
and  readjusted.  Both  stop-cocks  are  now  opened,  the  end  of  the  tube 
closed  with  the  finger,  and  water  poured  into  the  funnel  until  the  bulb 
and  tube  are  filled  to  overflowing.  The  cocks  are  then  closed,  and  the 
instrument  intrusted  to  an  assistant.  The  catheter,  well  oiled,  is  car- 
ried into  the  bladder,  and  as  the  water  is  escaping  the  lower  end  of  the 
rubber  tube  attached  to  the  evacuator  is  slipped  over  the  end  of  the 
instrument.  The  bulb  is  grasped  between  the  thumbs  and  fingers  of 
both  hands  and  squeezed,  thus  forcing  the  greater  part  of  its  contents 


Fio.  586. — Tlionipson's  iinj^roved  evacu- 
ator uud  catheters. 


STONE   IN  THE   BLADDER— LITHOTOMY.  589 

into  the  bladder.  It  is  now  allowed  to  expand,  the  water  rashes  back 
out  of  the  bladder  and  brings  with  it  the  smaller  jiarticles  of  stone  which 
fall  down  into  the  glass  sphere.  This  i)art  of  the  operation  may  be 
expedited  by  rapidly  half  emptying  the  bulb  into  the  bladder,  and  as 
rapidly  allowing  it  to  expand.  When  it  is  seen  that  particles  of  the 
calculus  cease  to  fall  into  the  receiver,  the  catheter  should  be  withdrawn, 
the  litho trite  reintroduced,  and  a  second  crushing  done.  The  bladder  is 
again  washed  out,  and  these  operations  should  be  alternated  until  all 
detritus  is  removed,  unless  alarming  symptoms  should  supervene,  when 
of  course  all  operative  measures  should  be  discontinued.  If  tlie  glass 
receiver  becomes  filled,  it  should  be  detached  and  emptied.  At  times 
particles  of  calculus  become  lodged  in  the  catheter  or  tube,  and  require 
to  be  dislodged  with  a  stylet.  From  one  to  two  hours  may  he  allowed 
for  this  operation  fi'om  the  commencement  of  the  anaesthesia.  The  prog- 
nosis will  be  more  favorable  with  the  shorter  period,  but  it  is  wiser  to 
proceed  carefully  and  remove  the  stone  thoroughly,  even  if  a  longer  time 
is  required.  The  absence  of  all  fragments  can  be  recognized  by  placing 
the  ear  over  the  bladder  at  the  symphysis  while  the  evacuator  is  being 
worked.  The  click  of  any  fragments  against  the  catheter  can  be  dis- 
tinctly heard.  The  introduction  of  a  sound  will  also  determine  the 
presence  of  any  pieces. 

In  the  after-treatment  opium  is  essential  to  relieve  pain  and  tenesmus. 
Citrate  of  potash,  grs.  xx,  three  or  four  times  a  day,  with  flaxseed-tea, 
will  render  the  urine  less  irritating.  The  soft  catheter  may  need  to  be 
employed  to  evacuate  the  bladder. 

In  incomplete  lithotrity  the  crushing  is  done  in  the  same  manner  as 
just  described.  A  fair  degree  of  anaesthesia  may  be  secured  by  the  em- 
ployment of  cocaine.  The  lithotrite  is  only  introduced  once,  and  not 
more  than  five  or  ten  minutes  are  consumed  in  the  ojjeration.  The 
evacuator  is  not  employed,  the  detritus  being  expelled  in  the  act  of 
urination. 

Cystotomy  or  Lithotomy. — Cutting  into  the  bladder  for  the  removal 
of  stone  is  performed  through  the  perina^um  or  through  the  abdominal 
wall,  just  above  the  symphysis  pubis.  Incision  through  the  rectum  in 
males  is  no  longer  a  recognized  jirocedure,  while  the  vesico-vaginal  <ipcra- 
tion  is  rarely  indicated. 

Supra-piihic  lifJiotomy,  or  the  7uf/7i  operation^  is  performed  as  follows: 
The  pubes  should  be  shaved  and  washed  with  sublimate  solution,  the 
pelvis  raised,  as  in  lithotrity,  so  that  the  intestines  will  gravitate  toward 
the  diaphragm.  The  bladder  should  be  thoroughly  irrigated  with  a 
warm  solution  of  Ijoracic  acid  (grs.  x-3  j),  and  from  a  pint  to  a  pint  and  a 
half  of  this  liquid  left  in  the  organ,  in  order  to  lift  the  anterior  redupli- 
cation of  the  iierittm.Tum  well  above  the  level  of  the  j)elvis.  The  incision 
should  be  made  in  the  linea  ajba,  commencing  three  and  a  half  inches 
above  the  symphysis,  and  extending  slightly  below  the  upper  margin  of 
the  pubic  bones.  All  the  tissues  should  be  divided  down  to  the  anterior 
wall  of  the  bladder,  ha?moiThage  arrested,  the  wound  packed  \n\\\  sub- 
limate sponges,  and  the  bladder  again  well  irrigateil.     If  any  difficulty 


590  A  TEXT-BOOK   OX   SURGERY. 

is  experienrpd  in  recognizing  the  \\;ill  of  this  organ,  it  fan  readily  be 
done  by  inrrodiicing  a  sound  by  the  urethra,  and  bringing  the  point  up 
above  the  i)ul)i.s.  where  it  may  be  felt.  While  it  is  still  distended,  a 
tenaculum  is  inserted  into  the  anterior  wall,  and  lirnily  held,  while  an 
assistant  introduces  a  catheter  and  empties  the  contents.  A  stout  silk 
ligatiiie  is  now  introduced  through  the  wall  of  the  bladder  on  either 
side  of  the  tenaculum.  These  threads  serve  as  retractors  in  controlling 
the  organ.  The  bladder  should  next  be  incised  parallel  with  the  linea 
alba,  between  the  sutures,  and  for  a  distance  of  al)out  one  inch  and  a 
half.  If  the  wound  is  now  well  dilated,  and  a  good  light  concentrated 
u]K)n  it,  a  full  \iew  of  the  cavity  of  the  organ  may  be  obtained.  If  the 
incision  should  prove  to  be  too  small,  it  should  be  enlarged.  If  the 
I)eritoneal  cavity  is  opened,  the  incision  in  this  membrane  should  be 
closed  at  once  by  catgut  sutures.  The  stone  may  be  located  by  inspec- 
tion or  b}^  digital  exploration,  and  i)icked  oi;t  with  an  ordinary  dressing- 
forceps.  The  edges  of  the  wound  in  the  bladder  are  now  carefully 
stitched  to  the  margins  of  the  incision  in  the  integument,  and  a  loo.se 
dressing  applied.  The  urine  is  discharged  by  the  wound  for  from  ten 
days  to  three  weeks,  Avhen  it  closes  by  granulation.  The  continuous 
employment  of  a  catheter  through  the  urethra  is  not  indicated.  The 
immediate  clo.sure  of  the  bladder  may  be  successful  in  some  instances, 
l)ut  involves  far  greater  danger  than  the  oi)eration  first  advised.  It  may 
be  necessary  to  lift  the  bladder  upward  by  the  introduction  of  a  rubber 
bulb  into  the  rectum,  which  is  carried  in  empty,  and  afterward  distended 
witii  warm  water.     A  Barnes  dilator  can  be  utilized  in  this  ]irf)cedure. 

Perineal  litliotomy,  or  the  low  operation,  may  be  done  l)y  three 
methods — the  lateral,  bilateral,  and  median  operations.  A  combina- 
tion of  the  median  and  lateral  incisions  is  sometimes  performed,  and  is 
known  as  the  nitdio-laterul  procedure. 

Lateral  litliotomy  is  thus  perfoi-med  :  Two  hours  before  the  operation 
the  rectum  should  be  emptied  by  a  free  enema  of  tepid  water,  and  the 
perinBBum  cleanly  shaved.  The  patient  should  be  j)laced  upon  the  back, 
the  sacrum  resting  near  the  edge  of  the  table,  the  thighs  flexed  toward 
the  abdomen,  slightly  alxlucted,  the  feet  brought  down  and  secured  to 
the  hands  and  wrists  by  several  turns  of  a  roller.  Each  leg  is  intrusted 
to  an  assistant,  while  a  third,  selected  for  his  special  fitness,  and  upon 

whom  the  duty  of  hold- 
■    —  ..^:^g5-:=;=;^s>      jjjo-  |^}jg  gulde  dcvolves, 

stands    beside    the    pa- 
tient's abdomen,   facing 

-FergussoD's  guide  for  lateral  lithotomy.  the  Operator. 

If  the  bladder  is  not 
fairly  distended  with 
urine,  a  Nelaton's  catheter  should  be  introduced,  and  about  a  pint  of 
lluid  injected.  A  Fergusson's  guide,  grooved  laterally'  (Fig.  087),  is  next 
carried  into  the  bladder.  The  probabilities  are  that  the  stone  will  be  felt 
by  the  sound.  If  the  calculus  has  been  recognized  within  a  day  or  two, 
and  if  in  the  mean  time  the  urine  has  been  carefully  watched  and  no 


STONE   IN  THE  BLADDER— LITHOTOMY. 


591 


solid  substance  has  escaped  by  the  urethra,  no  prolonged  effort  should 
be  made  at  this  juncture  to  demonstrate  its  presence. 

The  proper  posi- 
tion for  the  guide  is 
shown  in  Fig.  588. 
The  shaft  is  held 
about  perpendicular 
to  the  surface  of  the 
table,  the  point  well 
into  the  bladder,  while 
the  convexity  of  the 


curve    rests    against 


the   perinjeum.     The 

scrotum  is  now  lifted 

directly  upward,  and 

the  primary  incision 

is  made  with  the  sharp 

scalpel  (Fig.  63).     It 

commences  in  the  median  line  about  one  inch  and  a  half  directly  in 

front  of  the  anus,  and  is  carried  downward  and  outward  as  far  as  the 


Kia.  5S8. — Guide  in  position  in  lateral  lithotomy.     (After  Bryant.) 


Fio.  589. — C  D,  Line  of  incision  in  lateral  litliotnniy.      J3  A,  Imaginary  line  between  the  tuberoiiities  of 

the  iscliia.     (.\fter  Maelise.  i 

posterior  margin  of  the  anus,  jiassing  half-way  between  the  inner  sur- 
face of  the  patient's  left  tuber  ischil  and  the  anal  margin  (Fig.  589). 


592  A  TEXT-BOOK   ON   SURGKRY. 

The  integument  and  fascife  having  been  divided,  the  operator  proceeds 
through  the  upper  half  of  the  wound  by  cutting  down  upon  the  guide, 
which  may  be  readily  felt  with  the  finger.  When  this  is  neaily  reached, 
the  groove  in  this  instrument  will  be  made  out,  and,  by  jjicssing  the  nail 
of  the  left  index-linger  into  it,  the  point  of  the  knife  can  be  guided 
through  t!i(>  urethral  wall  into  the  groove,  making  an  opening  about  half 
an  inch  in  extent. 

With  the  linger-nail  kept  steadily  in  the  groove,  the  scalpel  is  laid 
aside,  and  the  long  i)r(jbe-poiiited  lithotomy-knife  (Fig.  04)  taken  up 
and  its  point  guided  into  the  groove  of  the  guide.  At  this  stage  of  the 
operation  the  sound  is  slightly  lifted  up,  so  that  the  pressure  which  has 
heretofore  been  made  upim  the  floor  of  the  urethra  will  be  tniiisferred 
to  its  roof.  While  doing  this  the  probe-point  of  the  knife  should  be 
firmly  and  steadily  pressed  upward  against  the  instrument,  for,  unless 
this  precaution  is  observed,  it  may  slip  out  of  its  proper  i)lace.  The 
operator  now  seizes  the  shaft  of  the  sound  with  the  left  hand  to  assure 
himself,  by  moving  this  instrument  slightly,  and  also  by  sliding  the 
knife  along  the  groove,  that  the  two  instruments  are  .in  actual  contact, 
and  then,  turning  the  cutting  edge  of  the  knife  obliquely  toward  the 
patient's  left  side,  and  more  nearly  parallel  with  the  transverse  than 
with  the  antero-posterior  diameter  of  the  patient's  body,  pushes  it  along 
the  grooved  guide  into  the  bladder.  In  executing  this  manoeuvre  it  is 
necessary  to  tilt  the  point  of  the  knife  upward  and  press  it  very  firndy 
into  the  groove  lest  it  slip  out  and  cause  confusion.  When  the  probe- 
point  arrives  at  the  end  of  the  groove  and  catches,  the  incision  through 
the  left  lobe  of  the  prostate  may  be  lengthened  by  j)ushing  the  sound 
with  the  knife  in  the  proper  direction.  As  the  incision  is  being  made,  a 
gush  of  urine  takes  place.  The  knife  is  now  withdrawn,  the  finger  car- 
ried into  the  bladder,  and  the  stone  located  'oefore  the  sound  is  removed. 
The  size  of  the  calculus  should  be  determined,  and,  if  necessary,  the 
lower  portion  of  the  primary  incision  may  be  enlarged.  While  this  is 
being  accomplished,  it  is  advisable  to  carry  the  index-finger  into  the 
rectum  to  avoid  wounding  this  gut. 

The  forceps  (Fig.  590)  should  now  be  introduced  and  the  stone  re- 
moved. This  instrument  can  not  always  be  carried  in  through  the  wound 
if  the  finger  is  allowed  to  remain,  and  is  at  times  difficult  of  introduc- 


Fio.  590. — Lithotomy -forceps. 


tion  without  a  guide.  To  prevent  delay,  the  conductor  (Fig.  591 )  should 
be  passed  along  the  finger  into  the  bladder  and  allowed  to  remain  after 
the  finger  is  withdrawn.  If  the  blades  of  the  forceps  are  now  closed 
upon  the  flange  of  the  conductor,  the  instrument  can  be  made  to  slide 


STONE  IN  THE   BLADDER— LITHOTOMY. 


593 


accurately  along  the  guide  into  the  bladder,  after  which  the  conductor 
should  be  removed. 


G.T!£MANN-  CO 


saBBims 


Fio.  591. — Scoop  and  conductor. 


In  removing  a  stone  with  the  forceps  two  precautions  are  essential : 
1,  not  to  pick  up  the  wall  of  the  bladder  with  the  calculus  ;  and,  2,  not 
to  employ  force  enough  in  grasping  the  stone  to  crush  it. 

When  the  stone  is  grasped,  if  the  instrument  can  be  moved  freely 
within  the  bladder,  it  is  evident  that  this  organ  is  not  caught. 

With  small  calculi  the  extraction  is  easily  accomplished.  When  the 
stone  is  large,  a  certain  amount  of  force  is  justifiable  and  necessary  to 
stretch  the  wound  to  its  utmost ;  but  this  force  should  never  be  used 
unless  the  operator  is  satisfied  that  the  stone  and  jaws  of  the  forceps 


Fig.  502.— (Jouley's  litlioclast. 


can  be  brought  through  the  wound  without  serious  injury  to  the  blad- 
der and  prostate.  If  the  stone  can  not  be  extracted  whole,  it  should  be 
crushed  with  the  forceps  or  lithoclast  (Fig.  592),  and  removed  in  frag- 


FiG.  593. — Lithotomy-scoop. 

ments.     The  larger  pieces  may  be  caught  with  the  forceps,  the  smaller 
with  the  scoop  (Pig.  598).     A  stream  of  water  should  also  be  forcibly 


\'aii   Huron's  debris-syringe. 


thrown  in  through  the  wound,  in  order  to  bring  awny  any  small  parti- 
cles which  may  have  escaped  notice  (Fig.  594).     Finally,  a  sound  should 

38 


594 


A  TEXT-BOOK   OX  SURGERY. 


be  introduced  and  searcli  made  for  a  second  stone  or  any  fragments 

lodged  in  the  more  remote  portions  of  the  bladder. 

Among  the  accidents  wliich  may  complicate  perineal  litliotomy,  in 

additi(>n  to  that  of  wounding  tlie  rectum,  which  has  Ijeen  mentioned,  is 

haemorrhage  from  the  artery  of 
the  bulb  and  other  vessels  of 
the  periiueuiu.  Tlie  ligature 
will  control  all  superticial  bleed- 
ing, and,  should  a  deep  vessel 
])e  divided,  it  may  be  transfixed 
with  a  tenaculum  and  tied,  or 
the  hook  allowed  to  ivmaiu  in 
the  wound  for  a  day  or  two.  If 
the  oozing  is  free  and  general, 
an  umbrella-compress  (Fig.  595) 

should  be  made  by  tying  a  piece  of  oiled  silk  or  rubber  tissue  to  a 

canula  or  bougie.     This  is  carried  into  the  wound  and  compression  made 

by  packing  sponges  beneath  the  cloth  which  is  brought  in  contact  with 

the  bleeding  surface. 


Fia.  595. — Umbrella-compresB. 


Fig.  596. — A  B,  Bulbous  portion  of  the  iirethra.  6',  Ki;,'ht  Literal  lobe  of  the  prost.ite.  J/,  The  line  of 
incision  in  lateral  lithotomy.  J>,  Corpus  cavernosum.  F,  Rectum.  j\',  V'esicula  scminalia.  (J,  Vaa 
dcterens.     Z,  Artery  of  the  bullj.     (After  Maclise.) 

The  after-treatment  of  lateral  lithotomy  is  simple.     The  wound  is  left 
open  and  unmolested.     The  urine  i)asses  through  this  for  a  few  days  or 


STONE  IN   THE  BLADDER— LITHOTOMY.  595 

weeks,  and  gradually  resumes  the  urethral  channel  as  the  incision  closes 
by  granulation.  In  some  cases  the  urine  passes  through  the  urethra  un- 
interruptedly.   The  patient  should  remain  in  bed  for  two  or  three  weeks. 

The  anatomical  relations  of  the  j'^U'ts  involved  in  this  operation  are 
shown  in  Fig.  59G. 

Bilateral  Litliotomy. — In  performing  this  operation  a  curved  incision 
is  made,  beginning  half-way  between  the  tuberosity  of  the  ischium  and 
the  anus  on  one  side,  and  terminating  at  a  corresponding  point  on  the 
other.  The  incision  crosses  the  median  raphe  of  the  periuc'eum  from  one 
half  to  three  quarters  of  an  inch  in  front  of  the  anus.  The  guide  used 
in  this  operation  should  be  grooved  deeply  in  the  middle  of  its  convex 
surface.  As  soon  as  this  instrument  is  reached,  the  urethra  is  opened  in 
the  membranous  portion,  and  the  finger-nail  carried  into  the  groove  on 
the  sound.  The  bisector — a  probe-pointed  two-edged  lithotome — is  in- 
troduced by  sliding  the  tip  of  the  instrument  along  the  nail  into  the 
groove.  The  operator  now  takes  hold  of  the  staff,  depresses  the  handle 
of  the  bisector,  and,  keeping  the  probe-point  in  the  groove,  pushes  the 
knife  into  the  bladder  directly  in  the  median  line.  In  this  operation 
the  prostate  is  divided  equally  on  both  sides  of  the  urethra. 

Median  Lithotomy. — The  position  of  the  patient  is  the  same  as  in 
the  two  preceding  operations.  The  best  staff  or  guide  is  that  of  Prof. 
Little  (Fig.  597),  which  has  a  deep,  wide  groove. 


GJIEMANN  &  CO 


Fio.  597.— Little's  lithotomy-stafi. 


It  is  introduced  and  held  in  such  a  position  that  the  shaft  is  perpen- 
dicular to  the  plane  of  the  body,  the  tip  well  in  the  bladder,  with  the 
convexity  of  the  instrument  pressing  firmly  and  steadily  toward  the 
perinseum.  The  finger  is  now  carried  into  the  rectum  in  order  to  guard 
against  puncture  of  the  anterior  wall  of  this  organ.  The  knife  (Fig.  53) 
is  entered  just  about  a  half-inch  anterior  to  the  anus  in  the  median  line, 
the  edge  of  the  blade  directed  upward,  and  is  pushed  straight  inward 
until  the  point  strikes  into  the  conc^avity  of  the  groove  in  the  staff  at 
the  anterior  limit  of  the  prostate.  It  is  then  made  to  cut  forward  and 
upward  until  the  membranous  portion  is  divided,  and,  as  it  is  with- 
drawn, the  incision  in  the  perinfeum  is  lengthened  in  all  about  one  and 
a  half  inch.  The  finger  is  now  introduced,  the  sound  withdrawn,  and 
the  wound,  prostatic  portion  of  the  urethra,  and  neck  of  the  bladder 
dilated  until  the  stone  can  be  felt  and  extracted  with  a  slender  forceps. 

Of  the  four  methods  of  cutting  for  stone  just  described,  the  lateral 
and  supra-pubic  o^jerations  are  preferable.     The  bilateral  procedure  is 


596  A  TEXT-BOOK   ON  SURGERY. 

at  this  time  rarely  performed.  In  the  extraction  of  nn  ordinary  stone 
the  incision  through  one  lobe  of  the  prostate  will  be  sufficient.  When 
the  calculus  is  so  large  that  a  wider  incision  is  required,  the  right  lobe 
may  be  readily  incised  through  the  lateral  wound.  Tlie  median  opera- 
tion is  objectionable  on  account  of  the  danger  of  injuring  the  prostate 
and  neck  of  the  bladder,  in  the  necessary  dilatation,  or  in  efforts  at  extrac- 
tion. It  is  only  applicable  to  the  removal  of  the  very  snudlest  calculi  in 
children  or  youths  in  whom  a  lithotrite  and  evacuating-catheter  can  not 
be  introduced.  Even  in  this  class  of  cases  the  lateral  operation  should 
be  given  the  preference.  The  supra-pubic  incision  has,  within  latt^  years, 
become  a  more  popular  operation.  It  is  applicable  (1)  when  the  stone 
is  of  large  size — from  one  and  a  half  to  two  inches  and  over  in  diame- 
ter— the  removal  of  which  by  a  perineal  incision  would  involve  an  ex- 
tensive incision  or  laceration  of  the  neck  of  the  bladder  and  prostate ; 
(2)  where  the  calculus  is  lodged  high  up  behind  the  i^ubes,  either  with 
or  without  enlargement  of  the  prostate  and  concentric  hypertrophy  of 
the  neck  and  base  of  the  bladder,  since  in  these  conditions  a  stcme  can 
be  reached  through  the  perinpcum  only  at  great  depth  and  with  much 
difficulty.  On  the  other  hand,  it  is  readily  found  through  a  supra-pubic 
incision.  The  high  ojoeration  is  indicated  in  deformity  of  the  pelvis, 
with  narrowing  of  the  inferior  strait.  The  difficulty  and  danger  of  this 
procedure  are  increased  in  corpulent  and  fat  perscms. 

Stone  in  the  Bladder  of  Females. — Vesical  calculi  are  not  met  with 
in  females  as  frequently  as  in  malee.  Many  conditions  which  ccm- 
diice  to  the  lodgment  or  formation  of  stone  in  the  male  bladder,  and 
are  common  in  this  .sex,  are  either  impossible  to,  or  rarely  occur  in, 
females.  Among  these  causes  may  be  mentioned  hypertrophy  of  the 
prostate  with  obstruction,  and  chronic  cystitis  and  organic  stricture  of 
the  urethra. 

Another  explanation  of  the  comparative  infi*equency  of  stone  in  fe- 
males is  the  short  and  dilatable  urethra,  allowing  the  escape  of  many 
small  concretions  which  in  men  would  lodge  in  the  cul-de-sac  behind  the 
prostate.  The  symptoms  do  not  differ  from  those  given  in  stone  in  the 
bladders  of  males.  The  diagnosis  rests  upon  exploration  with  a  searcher, 
combined  with  digital  exploration  ^jcr  vaginam,  and  direct  pressure  over 
the  pubes. 

Treatment. — The  large  majority  of  calculi  found  in  the  bladders  of 
females  may  be  readily  removed  by  lithotrity.  The  short  and  distensi- 
ble urethra  permits  of  the  introduction  of  the  largest  evacuating-cathe- 
ter, and  greatly  facilitates  the  operation.  The  crushing  operation  is 
preferable  in  small  stones  to  the  older  method  of  dilatation  or  divulsion 
of  the  urethra  and  extraction  in  mass  by  forceps.  A  mucli  larger  stone 
may  be  cmshed  and  removed  from  the  female  bladder  than  can  possibly 
be  done  from  the  male  organ  within  the  limit  of  safety  at  a  single  opera- 
tion. "When  lithotomy  becomes  necessary,  the  operator  must  choose 
between  the  vesico-vaginal  and  supra-pubic  incision.  In  the  former  a 
second  operation  for  vcsico-vaginal  fistula  is  essential.  In  case  the  pa- 
tient is  very  fat,  the  low  operation  will  be  advisable.     In  ordinary  sub- 


FOREIGN  BODIES  IN   THE   BLADDER. 


597 


Jects  tbe  supra-pubic  operation,  carefull}'  and  proj^erly  done,  offers  the 
best  prospect  of  speedy  relief. 

Foreign  Bodies. — Foreign  substances  in  the  bladder  are  usually  intro- 
duced through  the  urethra.  Less  frequently  they  pass  through  the  walls 
of  this  organ,  as  in  gunshot-wounds,  etc.  In  exceptional  instances  for- 
eign matter  finds  its  way  into  this  organ  through  a  fecal  or  vaginal  fistula. 
In  several  cases  of  this  character  worms  have  escaped  from  the  intestines 
and  found  an  exit  through  the  urethra. 

The  symptoms  are  usually  those  of  stone  in  the  bladder,  Avith  cystitis 
in  a  varying  degree.  The  diagnosis  may  be  evident  from  the  history  of 
an  accidental  or  intentional  introduction  of  the  foreign  subslance.  The 
matter  can  usually  be  recognized  by  the  searcher.  If  a  few  weeks  have 
elapsed,  the  sul^stance  will  probably  be  coated  with  a  deposit  of  urinary 
salts,  and  will  impart  to  the  sound  the  gmting  or  click  peculiar  to  stone. 

The  treatment  consists  in  removal  of  the  offending  substance  as  soon 
as  possible.  If  it  is  smaU,  round,  and  smooth,  it  may  be  extracted 
through  the  urethra,  with  the  lithotrite.  For  this  purpose  the  smallest 
instrument  should  be  employed.  If  it  is  too  large  to  be  brought  out  in 
mass,  it  may  be  chopped  up  or  crushed,  and  then  extracted  piecemeal, 
in  the  jaws  of  the  lithotrite,  or  washed  out  through  the  evacuator. 
Fig.  598  represents  an  English  gum  catheter  which  was  removed  in  this 


Fig.  598. — Gum  c.itheter  removed  from  the  bladder  b_v  the  lithotrite.     iThe  author's  case.) 


manner.  The  two  larger  pieces  were  grasped  by  the  end  and  drawn 
out ;  the  remainder  was  caught  in  the  lithotrite,  and  brought  out  one 
piece  at  a  time. 

When  the  substance  is  so  large  or  of  such  a  shape  that  it  can  not  with 
safety  be  brought  through  the  urethra,  cystotomy  is  imperative.  In 
determining  upon  the  method  of  o^^ening  into  the  bladder,  the  same  rules 
will  apply  as  given  for  lithotomy. 

The  Prostate  Bod)/. — Disease  of  the  prostate  is  almost  always  a  con- 
dition of  adult  life.  This  organ  is  rudimentary  in  childhood,  and  while, 
from  direct  injury,  as  in  catheterization,  lithotomy,  or  any  form  of  vio- 
lence, or  by  the  extension  of  any  of  the  rarer  foi-ms  of  disease  which 
affect  the  bladder  or  urethra  of  children,  this  body  may  be  involved,  it 
only  assumes  its  true  importance  after  it  has  taken  on  its  functional 
activity.  « 

Prostatitis. — Inflammation  of  the  prostate  mny  be  j^artial  or  comjilete, 
as  well  as  acute  and  chronic.     It  may  affect  the  epithelial  and  glandular, 


598 


A  TEXT-BOOK   ON   SUR(4ERY. 


or  niusc'ular  and  connective-tissue  structure  of  this  conij)lex  organ.  Pros- 
tatitis rarely  originates  in  the  sxibstance  of  this  body,  being  usually 
involved  by  extension  of  an  intianiniation  from  the  bladder,  urethra,  or 
other  organs  and  tissues  in  its  inunediate  neighborhood.  Urethritis, 
cystitis,  e])idydimitis,  and  proctitis  are  among  the  more  common  causes 
of  prostatitis.  To  these  may  be  added  excessive  venereal  excitement,  all 
forms  of  traumatism,  whether  by  violence  applied  to  the  rectal  or  perineal 
regions,  or  by  instruments  in  the  urethra,  and  the  presence  of  calcareous 
or  amylaceous  concretions. 

The  symptoms  are  usually  well  marked.  Pain  in  the  acute  fonn  of 
inflammation  is  usually  intense  and  burning  in  character.  There  is  a 
sense  of  fullness  and  throbbing  in  the  organ.  With  the  finger  in  the 
rectum  its  enlargement  may  be  appreciated,  together  with  abnormal  heat 
and  throl^bing  of  the  arteries  along  its  base.  Pain  is  increased  by  direct 
pressure  in  the  perinseum  or  rectum,  and  also  in  the  act  of  urination. 
Fever  is  present  in  proportion  to  the  severity  of  the  local  process.  Sup- 
pui-ation  and  the  formation  of  abscess  are  usually  indicated  by  exacerba- 
tions of  temperature  and  by  interference  with  micturition. 

The  first  indication  in  the  treatment  of  this  painful  affection  is  rest  in 
the  recumbent  posture.  The  bowels  should  be  kept  open.  The  ice-bag 
to  the  perineum  will  be  found  agreeable  and  of  value.  If  retention  of 
urine  occurs,  it  should  lie  relieved  by  the  use  of  the  smaller  soft  catheter. 
Supra-pubic  aspiration  may  be  demanded  in  severe  cases.  Scarification 
of  the  perinfeum  and  the  application  of  cups  are  highly  recommended  as 
local  measures.    If  abscess  exists,  it  should  be  evacuated  by  the  aspirator. 

Rupture  may  occur  into  the 
urethra,  or  the  abscess  may 
find  an  oi:)ening  through  the 
perinjeum  or  rectum. 

Ilypertroiiliy. — Chronic 
progressive  enlargement  of 
the  prostate  occurs  in  about 
one  third  of  all  males  who 
live  through  the  period 
from  fifty  to  seventy-five 
years  of  age.  The  increase 
in  volume  is  not  a  true  hy- 
perplasia, for  the  glandular 
functions,  as  well  as  the 
muscular  power  of  the  or- 
gan, decrease  with  the  hy- 
pertrophy. In  some  por- 
tions of  the  mass  the  mus- 
cular tissue  is  increased, 
but  the  bulk  of  the  enlarge- 

Fio.  59S. — Longitudinal  section  of  hypertrophied  prostate,  in  ment  is  due  tO  the  presence 
a  patient    sevcntv-foiir   years   ot"   acre  ;    showinfj   a  false  i      «.  t 

yiassage  tunneled  "by  a  catheter,     h.  Line  of  transverse  sec-  of  Uewly  formed  connective 

tion  shown  in  Fig.  600.    a,  Duct  of  vesicula  semiualis.  (Af-  , .  "  mi       •     i  i-        ■     • 

t«r  Socin.)  tissue.     Ihe  luduration  IS  in 


HYPERTROPHY   OF   THE   PROSTATE. 


599 


Flo.  600. — Transverse  section  through  the 
center  of  the  prostate  of  a  patient 
seventy-four  veal's  old.  Hypertrophy 
of  fourteen  years'  duration,  a,  Lrc- 
thra.  4,  Caput  frallmaguinis.  (After 
Socin.j 


proportion  to  the  excess  of  the  new  tissue  over  the  normal  muscular  and 
j^landular  elements.  In  some  instances,  though  rarely,  the  glandular 
elements  are  increased ;  but  this  is,  in  great  probability,  only  observed  in 
the  earlier  stages  of  hypertrophy,  before 
the  connective-tissue  elements  are  in  suf- 
ticient  quantity  to  cause  atrophy  of  the 
glandular  apparatus.  The  enlargement 
may  be  local  or  general.  In  general  hy- 
pertrophy, while  the  increase  in  size  is  in 
all  directions,  it  is  more  marked  in  the 
posterior  portions,  where  it  encroaches 
upon  the  neck  of  the  bladder.  Not  in- 
frequently one  lateral  lobe  is  greatly  en- 
larged, or  the  hypertrophy  may  be  cen- 
tral, resulting  in  the  development  of  a 
middle  or  third  lobe,  which,  by  progi-es- 
sive  enlargement,  not  only  changes  the 
axis  of  the  nonnal  urethra,  but  occludes, 
in  a  variable  degree,   the  outlet  of  the 

bladder.  This  last  condition  is  well  shown  in  Fig.  599,  and  that  of 
general  hypertrophy  of  the  muscular,  fibrous,  and  glandular  tissues, 
with  narrowing  of  the  urethra,  in  Fig  600. 

Symptoms. — The  increase  in  size  is  usuallj-  so  gradual  that  the  condi- 
tion of  hypertrophy  does  not  attract  the  attention  of  the  patient  until 
interference  with  the  How  of  urine  occurs.  As  a  result  of  retention  the 
bladder  is  distended,  the  contractility  of  its  muscular  walls  is  diminished, 
and  chronic  cystitis  inevitably  ensues.  The  changes  which  take  place  in 
this  organ — thickening  of  the  walls,  occasional  sacculation,  the  fonnation 
of  calculi,  dilatation  of  the  ureters,  etc. — have  been  given.  In  severe 
cases  the  functions  of  the  rectum  may  be  interfered  with. 

The  diagnosis  may  be  determined 

^ff°r^  ,  by   the   presence   of   the   symptoms 

^.  just  given,  by  digital  exploration  by 

the  rectum,  and  the  introduction  of 
a  sound  or  bougie  by  the  urethra. 

The  treat  me  lit  is  chiefly  pallia- 
tive. When  recognized  early  in  its 
history,  every  source  of  irritation 
should  be  removed  from  this  organ. 
The  bowels  should  be  kept  open, 
the  iriitnbility  of  the  urine  dimin- 
ished by  the  administration  of  alka- 
line diluents,  and  all  venereal  ex- 
citement prohibited.  In  those  af- 
fected with  gout  or  rheumatism, 
judicious  diet  and  medication  may 
aiTest,  or  at  least  retard,  the  prog- 
ress of  the  disease  in  the  prostate. 


Fig.  601. — .Showins  the  relations  of  the  floor  of 
the  bladder  to  the  prostatic  urethra  in  the 
normal  condition  of  this  body.  The  bristle 
is  passed  from  the  ejaoulatory  duct  into  the 
uretiiru.     {.\rter  Socin.) 


(500 


A  TEXT-BOOK   ON   SURGERY. 


When  symptoms  of  obstruction  to  the  escape  of  urine  supervene,  oper- 
ative interference  is  frequently  culled  foi-.  If  the  hypertrophy  is  gen- 
eral, and  the  caliber  of  tlie  urethra  is  encroached  upon,  dilatation  by 
means  of  the  olive-pointed   French  bougies  or  the  conical  steel  sounds 


Fia.  G02.^Hypertropliy  of  the  prostate,  elinwin^'  tlie  nsyminetrical  development  of  tlio  miiliUo  or  tliiid 
lobe,     o  a,  Openings  of  ureters.     (Alter  Socin.) 

may  be  required.  When  the  enlargement  is  chiefly  in  the  posterior 
portions  of  the  organ,  dilatation  is  not  indicated.  In  order  to  i^revent 
cystitis,  it  is  important  that  every  effort  should  be  made  to  thoroughly 
empty  the  bladder  at  each  act  of  urination. 

The  relation  of  the  urethra  to  the  base  of  the  bladder,  in  the  normal 

condition  of  the  prostate,  is 
well  shown  in  Fig.  601.  The 
inqiediment  to  the  complete 
evacuation  of  the  bladder  in 
enlargement  of  the  posterior 
and  middle  portions  of  this 
body  may  be  more  readily 
understood  by  referring  to 
Figs.  6()2  and  (303. 

If  the  sitting  or  standing 
posture  is  maintained,  it  is 
evident  that  a  certain  quan- 
tity of  urine  will  remain  in 
the  cul-de-sac,  behind  the 
prostate,  even  if  the  ball- 
valve  formed  by  the  hyper- 
trophied  middle  lobe  is  held 
back  by  the  catheter.  In 
many  cases  this  difficulty 
may  be  overcome  and  benefit  gained  by  evacuating  the  bladder,  with  or 
without  the  catheter,  in  the  knee-shoulder  position.     The  introduction 


Fig.  003.— Antcro-posterior  section  ot  the  same  specimen. 


HYPERTROPHY   OF   THE   PROSTATE. 


601 


of  the  catheter  in  prostatic  hypertrophy  is  such  an  important  feature  in 
the  treatment  of  this  disease,  and  at  times  is  surrounded  with  such  diffi- 
culties, that  it  becomes  important  in  each  case  to  study  the  condition  of 
the  neck  of  tlie  bladder  and  urethra,  to  determine,  with  as  much  accu- 
racy as  possible,  the  deviation  of  this  channel  from  the  normal. 


Fig.  604. — The  norm.il  urethra  of  a  luak-  uilult.     From  a  frozen  section.     Reduced  from  life  size. 

^After  Braune.) 

The  normal  curve  of  the  urethra  is  shown  in  Figs.  604,  605.     When 
hypertrophy  of  the  prostate  occurs,  the  distortion  is  practically  an  elon- 
gation   and    exaggeration   of    the 
natural  curve  from  the  triangular 
ligament  back  to  the  opening  into 
the  bladder  (Figs.  606,  607). 

In  the  exploration  an  olive- 
pointed  black  French  catheter,  in 
size  about  No.  14  (U.  S.  scale),  will 
be  found  to  be  a  safe  and  satisfac- 
tory instrument.  If  warmed  and 
oiled,  it  will  usually  pass  to  the 
neck  of  the  bladder  without  resist- 
ance, and,  in  a  majority  of  in- 
stances, the  obstruction  may  be 
overcome  by  i)usliing  steadily  upon 
the  catheter.  No  harm  can  arise 
from  this  procedure.  If,  however, 
the  bladder  is  not  entered,  the  in- 
strument should  be  withdrawn,  armed  with  the  wire  stylet,  bent  to 
suit  the  curve  of  the  deep  urethra,  and  again  introduced.  A  carefui 
degree  of  force  may  now  be  employed   to  overcome   the  obstruction, 


Fio.  605. — The  sound  passing  around  the  normal 
curve  of  the  uretlira.  (.\fter  Van  Buren  and 
Keyes.) 


G02 


A  TEXT-BOOK   ON     SURGERY. 


but  uudne  violence  must  be  avoided.      Tlie  distal  end  of  the  catheter 
and  stylet  should  be  well  depressed  in  the  etfort  to  pass  by  the  obstruc- 


Fio.  606.— The  change  in  the  direction  of  the  urethra  causetl  by  hypertrophy  of  the  prostate,     ('.\ftcr  Socin.) 

tion.  If  the  manoeuvre  is  successful,  the  stylet  is  withdrawn,  leaving 
the  catheter  in  position  until  the  bladder  is  emptied.  If  the  intro- 
duction can  not  be  effected,  supra-pubic  aspiration  may  be  done,  and 

the  patient  should  be  put 
to  bed  and  narcotized  with 
morphia.  Under  the  quiet- 
ing influence  of  this  rem- 
edy spasm  of  the  muscu- 
lar fibers  of  the  prostate 
and  vesical  neck  is  allayed, 
frequently  resulting  in  tem- 
porary relief  from  reten- 
tion. Its  value  can  scarce- 
ly be  overestimated  in  the 
management  of  obstinate 
cases  of  retention  and  cys- 

Fio.  60r.— Showing  the  increase  in  the  curve  of  the  uretlira       titis  CaUSed  by  prOStatlc  hy- 
in  prostatic  hypertrophy,  and  the  necessity  of  a  longer  ■, 

curve  in  the  catlieter.    (Alter  Van  Biu«n  and  Keyes.j  pertropuy. 


HYPERTROPHY   OF   THE  PROSTATE. 


603 


The  propriety  of  operative  iuterferenre,  beyond  catheterization  or 
puncture  of  the  bladder,  may  be  entertained  in  a  certain  proportion  of 
cases.  When  the  obstruction  is  due  to  hypertrophy  of  the  middle  lobe 
(Figs.  602,  603,  and  608),  relief  may  be  obtained  by  the  ojjei-ation  of  INIer- 
cier.  The  excisor  is  shown  in  Fig.  609.  In  con- 
struction it  resembles  the  lithotrite,  with  the  ex- 
ception that  the  beaks  are  shorter  and  are  not 
seiTated.  The  mechanism  of  the  instrument  is 
practically  the  same.  The  operation  is  performed 
as  follows  :  The  kiotome  is  closed,  oiled,  and  car- 
ried into  the  bladder,  which  should  be  fairly  dis- 
tended. The  operator  should  move  the  Instrument 
about  freely,  and  turn  it  on  its  axis,  in  order  to  be 
assured  that  it  is  well  within  the  organ. 


Fio.  608. — A  ridiie  of  hypertrophied  prostate  seen  from  witliin  the  bl.idder. 
(Alter  Socin.) 


It  is  then  withdrawn,  with  the  beak  pointing 
upward,  xmtil  it  is  felt  to  be  arrested  at  the  open- 
ing into  the  urethra.  While  in  this  position  the 
blades  are  separated  a  half-inch,  the  instrument 
forced  to  one  side  (the  patient's  right),  then  stead- 
ily turned  to  the  left  and  closed.  If  the  obstruc- 
tion is  seized  by  this  manopuvre  the  screw-move- 
ment is  adjusted  and  the  part  grasped  is  cut  off 
and  withdrawn  with  the  closed  instrument.  Mer- 
cier's  procedure,  although  not  frequently  per- 
formed, has  met  with  a  success  which  justifies  its 
repetition.  In  well-selected  cases  it  can  not  but  be 
useful,  and  when  the  urethra  and  bladder  are  care- 
fidly  accustomed  to  the  use  of  a  catheter,  it  gives 
little  pain  or  inconvenience.  The  employment  of 
an  ana3sthetic  is  not  indicated,  the  sensation  of  the  patient  being  of 
value  in  aiding  the  surgeon  to  determine  when  the  tissue  is  grasj^ed. 

In  hopeless  cases  of  cystitis  resulting  from  obstruction  of  the  urethra, 
from  prostatic  hypertrophy,  cystotomy,  with  the  establishment  of  a  per- 


i'lc.  iW'.i.— Moreior's  instru- 
ment for  the  removal  of 
portions  of  the  hypertro- 
phieil  prostate,  'flie  eiit- 
tiiit^  poitinh  (b)  is  life  size. 
(.\fter  Socin.) 


(504  A  TEXT-BOOK   ON   SURGERY. 

nianent  urinary  fistula,  may  become  necessary.  The  various  methods  of 
performing'  this  operation  have  already  been  described. 

Proiitatorrhoea. — Chronic  prostatitis,  or  catarrh  of  the  prostate,  in  a 
majority  of  cases  follows  an  acute  intlammaticm  of  this  organ.  Its  chief 
cause  is,  tl;erefore,  an  extension  of  a  cystitis  or  urethritis  to  the  epi- 
tlielial  lining  of  the  glandular  portions  of  this  body.  In  a  certain  pro- 
])orti()n  of  cases  it  originates  as  a  subacute  inflammatory  jirocess  located 
in  the  glandular  sul)stance.  It  is  in  this  form  most  fre(juently  seen  in 
weak,  scrofulous,  or  tubercular  adults  about  the  period  of  puberty. 
Prostatorrho^a  is  a  symptom  of  general  hypertro])hy  of  this  organ  in 
the  earlier  stages  of  enlargement,  gradually  diniiuishiug  as  the  connect- 
ive-tissue hyperplasia  encroaclies  upon  and  destroys  by  compression 
the  glandular  ajiparatus. 

The  leading  symptom  of  this  disease  is  the  discluirge  of  a  small 
quantity  of  bluish-white  fluid  from  the  meatus.  It  is  noticed  particu- 
larly by  the  patient  before  the  first  micturition  in  the  morning,  having 
accumulated  during  the  night.  A  drop  or  two  may  be  squeezed  from 
the  urethra  by  pressure  along  the  under  surface  of  the  penis  from  the 
perinreura  forward.  It  is  carried  out  with  the  first  flow  of  iirine,  and, 
if  not  observed  previously,  usually  escapes  notice.  In  the  severer  type 
of  cases  the  iirostatic  fluid  may  be  seen  immediately  after  urinating 
or  during  the  intervals  of  micturition,  as  a  bluish  mucus,  moisten- 
ing the  meatus  and  prepuce,  and  slightly  tenacious  and  stringy  when 
wiped  off.  This  fluid  is  also  frequently  observed  when  the  contents 
of  the  rectum  are  discharged,  especially  if  the  faeces  are  hard  and  fully 
formed.  Prostatorrhoea  occurs  in  excessive  or  prolonged  venereal  ex- 
citement. 

The  diagnosis  of  this  affection  depends  upon  the  exclusion  of  sper- 
matorrhani  and  urethritis.  The  symptoms  of  spermatorrhoea  are  in  gen- 
eral so  similar  to  those  of  prostatorrhoea,  that  a  positive  differentiation 
can  only  l)e  made  by  microscopical  examination.  The  fluid  which  es- 
capes may  be  examined  alone,  or  the  first  ounce  or  two  of  urine  passed 
after  a  comparatively  long  interval  in  urinating  may  be  caught  in  a  sepa- 
rate vessel,  allowed  to  settle,  and  a  drop  of  the  sediment  placed  ujion 
the  slide.  The  presence  of  spermatozoa  will  confirm  the  diagnosis  of 
spermatorrhea.  The  urine  first  jiassed  after  a  discharge  of  semen  should 
not  be  examined,  since  under  such  conditions  these  elements  are  found 
in  perfectly  normal  subjects.  In  differentiating  between  prostatorrhoea 
and  gleet,  the  exploration  of  the  ui-ethra  will  be  necessary.  The  absence 
of  a  stricture  or  of  marked  tenderness  in  the  canal  in  front  of  the  pros- 
tatic portion  will  exclude  urethritis,  with  the  exception  (^f  a  rare  form 
of  chronic  follicular  urethritis,  which,  as  will  be  seen  further  on,  may 
or  may  not  be  preceded  by  a  gonorrhoea  or  stricture.  In  follicular  ure- 
thritis, tenderness  is  not  marked.  If  a  large-sized  bulbous  wire  bougie 
is  carried  back  to  the  membranous  portion  of  the  urethra,  and  is  then 
withdrawn  while  the  urethra  is  held  in  close  contact  with  it,  the  yellow- 
ish-white flakes  or  plugs  of  cheesy  material  will  be  squeezed  out  of  the 
follicles  and  be  seen  adhering  to  the  bulb. 


PROSTATORRHCEA. 


605 


Treatment. — The  correction  of  any  diathesis  which  predisposes  to  a 
catarrhal  condition  of  the  mucous  membranes  is  an  important  step  in 
the  general  treatment  of  prostatorrhoea. 

Among-  the  local  measures,  distention  of  the  prostatic  urethra  by  the 
introduction  of  steel  sounds,  is  advisable. 


The  larger  sizes  should  be 


Fig.  IJIO. — Van  Bureu's  cupped  sound. 

employed,  and  if  the  meatus  is  so  narrow  that  it  will  not 
admit  No.  20  or  21  (U.  S.),  it  should  be  incised  up  to  this 
point  as  a  preparatory  measure.  When  stricture  exists, 
internal  urethrotomy  should  be  perfonned.  The  dilatation 
may  be  commenced  with  No.  17  and  increased  to  No.  21  at 
a  single  operation  ;  or,  if  the  procedure  is  attended  with 
pain  of  a  severe  nature,  the  larger  numbers  may  be  used  at 
the  third  or  fourth  introduction.  The  point  of  the  sound 
should  not  be  carried  farther  than  the  neck  of  the  blad- 
der, which  is  between  seven  and  eight  inches  from  the 
meatus.  The  operation  should  be  repeated  from  two  to 
three  times  a  week — not  often  enough  to  cause  a  general 
urethritis. 

Local  medication  is  at  times  of  great  value.  The  cupped 
sound  (Fig.  610),  which  consists  of  an  ordinary  instrument 
with  from  six  to  eight  spoon-shaped  depressions  just  be- 
yond the  curve,  is  a  valuable  instrument.  In  employing 
it,  a  stiff  salve  must  be  made  by  mixing  the  medicine  re- 
quired with  simple  cerate.  Lard  melts  too  rapidly,  and  is 
therefore  objectionable.  The  cups  are  filled  just  to  the  level 
of  the  surface,  the  instrument  thoroughly  lubricated  and 
rapidly  carried  down  t6  the  prostate,  where  it  is  allowed 
to  remain  for  several  minutes,  until  the  heat  of  the  part 
melts  the  salve.  Tannic  acid  (grs.  x-xx,  or  xxx  to  §  j)  or 
acetate  of  lead  or  nitrate  of  silver,  in  proper  proportions, 
may  be  thus  employed. 

Another  method  is  the  introduction  of  silver  nitrate  or 
other  escharotics  or  astringents  by  means  of  the  canulated 
sound  (Fig.  611),  which  consists  of  a  metal  tube  shaped  like 
a  catheter,  through  which  a  stylet-piston  plays.  A  suffi- 
cient quantity  of  the  ointment  is  placed  in  the  cylinder 
near  its  open  end,  and  the  piston  introduced.  When  the 
tip  of  the  instrument  arrives  at  the  i:)rostate  it  is  emptied 
by  forcing  the  piston  down,  at  the  same  time  slightly  with- 
drawing the  catheter  in  order  to  distribute  the  contents  over  the  entire 
prostatic  surface. 


Flo.  till. — Gar- 
re  au' 8  pros- 
tatic svrintrc. 
(^  After 'Sociii.) 


006  A  TEXT-BOOK  ON   SURGERY. 

It  is  readily  understood  that,  locally  applied,  no  agent  is  carried  to 
the  deeper  portions  of  the  glandular  substance,  but  the  inflammation 
precipitated  in  the  more  supi'rficial  glands  and  the  ducts  of  those  more 
deeply  situated,  may  readily  travel  along  the  epithelial  lining  until  the 
entire  gland-tissue  is  involved. 

Beyond  the  danger  of  a  temporary  elevation  of  tenqiei-ature  which 
may  occur  in  patients  subjected  to  urethral  exploration,  the  additional 
dangers  of  cystitis  and  epididymitis  should  not  be  disregarded.  Tiie 
use  of  the  doubh^-current  closed  catheter,  with  hot  or  colli  water,  is 
one  of  the  most  satisfactory  and  safe  methods  of  treating  this  disease. 
Its  employment  will  be  described  in  the  treatment  of  chronic  follicular 
urethritis.  Tiie  jtrognosis  in  i)rostatorrh(r'a  should  be  guarded,  for  many 
cases  obstinately  resist  the  most  careful  and  energetic  measures  of  treat- 
ment. 

Sjjermatorrlicea. — This  term  is  used  to  designate  the  escape  of  semen 
from  the  ejaculatory  ducts  without  an  orgasm.  This  tiuid  may  find  its 
way  into  the  bladder,  but  usiudly  escapes  by  the  meatus.  The  symp- 
toms of  this  disease  do  not  differ  materially  from  those  given  in  pros- 
tatorrhoea.  The  diagnosis  can  only  be  made  certain  by  the  recognition 
of  the  spemuitozoa  with  the  aid  of  the  microscope.  It  occurs  at  times  in 
conditions  of  great  physical  prostration,  as  a  result  of  excessive  and  un- 
natural venereal  indulgence,  and  from  interference  with  the  function  of 
the  muscular  elements  of  the  prostate. 

The  treatment  is  general  and  local.  Measures  looking  to  the  im- 
provement of  the  moral  and  physical  condition  of  the  patient  should  be 
adopted.  The  local  treatment  is  the  same  as  that  given  for  jirostator- 
rha>a. 

Aspermatlffm. — The  spermatozoa  are  wanting  in  adults  whose  testi- 
cles have  been  removed  or  destroyed  by  disease,  in  ])atients  in  whom 
both  organs  have  failed  to  descend  and  have  undergone  atroi)hy  ;  in  all 
cases  of  complete  obstruction  of  the  vasa  deferentiu  or  ejaculatory  ducts, 
and  in  certain  cases  of  senile  atrophy  of  these  organs.  These  conditions 
are  rarely  amenable  to  surgical  treatment. 

TnherculoHh  of  the  Prostate. — Tubercular  disease  of  this  organ, 
tlujugh  rarely  observed,  may  be  primary,  or  more  frequently  is  second- 
ary, to  tubercular  deposit  in  other  viscera,  as  the  testis,  epididymis, 
lungs,  etc.  It  is  more  apt  to  occur  in  the  young  and  middle-aged  than 
in  the  old.  The  diagnosis  can  not,  as  a  rule,  be  easily  made.  In  some 
cases  there  are  no  symptoms  of  tuberculosis.  If  with  a  subacute  or 
chronic  lesion  of  this  organ  there  is  a  history  of  phthisis,  the  deposit  of 
tubercular  matter  may  be  suspected.  When  the  febrile  movement,  hec- 
tic, profuse  sweats  and  emaciation  of  this  disease  are  present,  a  correct 
diagnosis  is  readily  made.  The  enlargement  and  nodular  character  of 
the  prostate  may  be  made  out  by  digital  exploration  by  the  rectum.  The 
treatment  is  altogether  palliative. 

Carcinoma. — Cancer  of  the  prostate  is  also  rare.  It  is  more  apt  to 
occur  primarily  than  by  metastasis.  Primary  cancer  of  this  organ  is 
more  frequently  seen  in  young  adults  than  in  the  old.     In  the  middle- 


PROSTATIC   CONCRETIONS. 


607 


aged  and  old  it  is  more  likely  to  occur  by  iavasion  from  a  neighboring 
organ,  as  the  rectum. 

In  the  earlier  stages  the  symptoms  of  tliis  disease  do  not  differ  mate- 
rially from  those  of  simple  hypertrophy.  As  simple  hyperti-ophy  is  rare 
in  the  young  and  middle-aged,  the  presence  of  a  tumor  of  this  organ  at 
this  time  of  life  should  be  regarded  with  a  suspicion  of  malignancy. 
The  absence  of  the  symptoms  of  abscess  is  in  some  degree  a  confirma- 
tion of  this  suspicion.  If  the  tumor  develops  rapidly,  carcinoma  or 
sarcoma  may  be  diagnosticated,  for,  although  the  disease  may  continue 
for  one  or  two  years,  or  even  longer,  the  invaded  organ  soon  assumes  a 
size  not  met  with  in  non-malignant  hypertrophy.  Haemorrhage  of  a  pro- 
fuse character  is  apt  to  follow  the  introduction  of  a  sound  or  catheter 
wlien  carcinoma  or  sarcoma  is  present. 

Sarcoma  is  also  rare  in  this  organ  (Fig.  612).  It  is  more  apt  to  oc- 
cur in  the  young  than  in  the  middle-aged  and  old.  The  symi)toms  differ 
in  no  essential  feature  from  those  present  in  cancer.  The  progiiosiH  of 
both  diseases  is  grave,  and  the  treatment  palliative. 

Prostatic  Concretions. — Concre- 
tions in  this  organ  are  of  two  kinds — 
the  corpora  amylacea  and  calculi. 


«^ 


f  lo.  612. — Sarcoma  of  the  prostate  and  neck  of 
the  bladder,  with  obstruction.  Tlie  catlieter 
has  tunneled  the  neoplasm.     (After  Sociu.) 


^  ^^4^^=-; 
*  -  '^-.-7-'- 


FiG.  613.— Calculi  in  the  prostatic  follicles. 
^AJter  Socin.) 


The  former  are  small  bodies  wliich  frequently  exist  in  the  follicles  of 
the  prostate.  Their  mode  of  origin  is  unknown.  They  give  the  well- 
known  amyloid  reaction  witli  iodine.  Stone  in  the  prostate  may  origi- 
nate in  the  deposit  of  inorganic  elements  from  the  blood  and  fluids  of 
this  organ,  either  in  the  follicles  originally  (Fig.  613)  or  as  accretions 
upon  the  amyloid  bodies  just  described. 

The  symptoms  of  prostatic  concreticms  are  chiefly  those  due  to  the 
inflammation  or  enlargement  which  they  produce.  Corpora  amylacea 
not  infietpiently  exist  in  the  iirostate,  causing  little  or  no  discomfort. 
When  of  large  size,  especially  when  they  grow  by  reason  of  a  deposit 
of  inorganic  substances,  they  cause  inflammation  of  the  follicles  and 
destruction  of  the  glandular  ejjithelia.  A  positive  diagnosis  can  onlj' 
be  made  by  bringing  a  sound  or  catheter  in  contact  with  the  concreticm. 
When  the  stone  is  situated  in  the  deeper  portions  of  the  organ,  it  will 


008  A  TEXT-BOOK   ON   SURGER\. 

escape  detection  by  tins  method,  but  tlie  tumefaction  it  cutises  mny  be 
recognized  l)y  digital  exploration  per  rectum. 

The  interference  with  the  escape  of  urine  caused  by  calculi  of  the 
prostate  is  analogous  to  that  which  occurs  with  general  hypertrophy  of 
the  body  of  this  organ.  The  stream  of  urine  is  diminislied,  but  remains 
about  the  same  size,  and  escapes  steadily  throughout  the  act  of  urination. 
There  is  no  sudden  and  comi)lete  interruption  of  the  current,  as  in  stone 
in  the  bladder,  or  in  enlargement  of  the  middle  lobe  of  the  prostate. 
Calculi  of  this  organ  may  escape  into  the  urethra  and  lodge  there,  or 
work  their  way  back  miu  the  bladder,  or  pass  out  at  the  meatus. 

The  treatinent  is  palliative  until  operative  interference  is  necessitated 
on  account  of  dysuria.  The  incision  is  the  same  as  given  for  median 
lithotomy.  The  prostate  should  not  be  incised  if  it  can  be  avoided. 
The  stone  may  be  removed  with  the  scoop  or  narrow  forceps. 

Neuralgia  of  the  prostate  and  neck  of  the  bladder  is  occasionally  met 
with.  Pain  is  present  in  this  organ  when  no  symptoms  of  inilammaticm 
are  discoverable.  It  is  usually  exaggerated  during  and  immediately 
after  micturition,  and  after  a  seminal  emission.  The  introduction  of  a 
sound  shows  great  tenderness  of  the  deep  urethra.  The  instrument  car- 
ried into  the  bladder  does  not  produce  the  tenesmus  and  pain  common 
to  cystitis.  An  examination  of  the  urine  will  demonstrate  the  absence  of 
pus,  wMch  will  also  serve  to  exclude  inflammation  of  the  bladder  or 
prostate.  The  causes  of  this  affection  are  as  a  rule  obscure.  Irregular 
or  excessive  venereal  indulgence  is  considered  to  be  one  of  the  most 
frequent  causes  of  neuralgia  in  this  organ.  The  treatment  involves  the 
removal  of  every  possible  source  of  irritation.  The  constitutional  meas- 
ures recommended  in  neuralgia  in  other  jrATts  of  the  body  should  be 
employed.  Locally  the  galvanic  current  is  especially  indicated.  If  the 
urine  is  extremely  acid  and  burning,  benefit  will  be  derived  from  the 
administration  of  large  quantities  of  alkaline  and  diluent  drinks. 


The  Urethra. 

Urethritis. — Inflammation  of  the  urethra  may  be  traumatic  or  idio- 
pathic, specific  or  non-si3eciflc,  local  or  general.  Among  the  more  freqiient 
causes  of  traumatic  urethritis  are  direct  violence  from  without,  applied 
to  the  perinjeum  or  penis  ;  violent  and  excessive  sexual  intercourse  ;  the 
introduction  of  instruments  or  corrosive  substances ;  and  the  lodgment 
of  foreign  bodies  carried  in  from  without,  or  of  vesical  or  prostatic  cal- 
culi, etc.  It  is  usually  of  short  duration,  mild  in  character,  and  involves 
only  a  limited  portion  of  the  canal. 

The  treatment  demanded  is  rest,  the  removal  of  the  cause  of  the 
in'itation,  and  the  dilution  of  the  urine  by  the  exhibition  of  alkalies 
and  diuretics. 

Specific  urethritis  (gonon-hcea)  is  a  violently  contagious  disease  affect- 
ing the  mucous  membrane  of  this  canal,  at  times  extending  into  the 
bladder  and  seminal  vesicles,  and  along  the  vasa  deferentia  to  the  epi- 


URETHRITIS.  609 

didymis  and  testicle.  The  exact  nature  of  the  virus  is  unknown.  It  is 
claimed  that  the  pus-corpuscles  of  the  gonorrhoea!  discharge  contain  an 
organism  (gonococcus)  peculiar  to  themselves ;  l)ut  this  claim  is  not  as 
yet  satisfactorily  dem(jnstrated  nor  widely  accepted. 

When  the  virus  is  brought  into  contact  with  a  mucous  surface,  the 
period  of  time  which  elapses  befijre  the  local  symptoms  of  inflammation 
are  noticeable  will  vary  in  different  individuals,  and  even  in  the  same 
patient  at  different  inoculations.  It  is  very  probable  that  the  condition 
of  the  mucous  membrane  at  the  time  of  the  contact  has  more  to  do  with 
the  rapid  appearance  of  the  inflammation  than  any  variableness  in  the 
quality  of  the  virus.  The  period  of  incubation  may  range  from  a  few 
hours  to  several  days,  and  in  some  very  excepticmal  instances  as  much  as 
two  weeks  have  elapsed  between  the  contact  and  the  recognition  of  the 
inflammatory  process.  The  limit  between  twenty-four  hours  and  three 
days  will  include  a  large  majority  of  cases  of  specific  urethritis. 

Usually  the  earliest  symptom  of  gonorrhoea  is  a  biirning  sensation  at 
the  meatus,  which  is  more  acute  as  the  urine  is  escaping.  The  lijis  of  the 
meatus  soon  become  swollen  and  unusually  prominent  and  red.  If  care- 
fully separated,  a  film  of  muco-pus  will  be  seen  to  coat  over  the  mucous 
membrane. 

The  flrst  stage  of  the  disease  may  be  considered  as  beginning  with  the 
date  of  contact  with  the  virus,  and  ending  with  the  first  appearance  of 
the  suppuration.  The  average  duration  of  this  stage  is  from  two  to 
ten  days.  From  this  period  the  inflammatory  symptoms  increase  for 
from  three  or  four  days  to  as  much  as  two  weeks.  The  qiiantity  of  pus 
discharged  varies  from  a  few  di'ops  to  several  drachms  in  the  twentj'-four 
hours.  It  is  increased  by  exercise  as  well  as  by  imjiroper  diet.  The 
color  varies  from  the  bluish-white  hue  of  the  first  few  droj)s  to  the 
yellow  or  yellowish-green  tinge  of  that  discharged  during  the  height  of 
the  inflammatory  process.  In  some  instances  it  becomes  stained  with 
blood,  as  a  result  of  the  rupture  of  capillaries  in  the  engorged  mucous 
membrane. 

The  second  star/e,  or  tliat  of  increasing  inflammiation  and  svppura- 
tion,  lasts  usually  about  twelve  days,  and  is  followed  by  the  third  stage, 
or  that  of  decreasing  inflanimation  and  supjyiiration,  the  duration  of 
which  period  is  usually  from  three  to  six  weeks. 

In  addition  to  the  purulent  discharge  and  the  pain  which  characterizes 
the  second  stage  of  this  disease,  there  is  also  a  diminution  in  the  size  of 
the  stream  of  urine,  due  to  the  swollen  and  puffy  condition  of  the  mucous 
membrane  of  the  urethra.  In  the  milder  foi-ms  of  gonorrhoea  no  oth- 
er sj'mptoms  are  present  in  the  second  stage.  Not  infrequently,  how- 
ever, the  inflammatory  process  extends  into  the  prostatic  urethra,  and 
thence  to  the  bladder  or  along  the  seminal  ducts  to  the  vesicles  and 
testes.  Iiiflltration  of  the  vascular  erectile  tissue  of  the  corpus  s])on- 
giosum  occurs  in  a  varying  degree  in  all  instances,  and  occasionally  the 
exudation  extends  into  the  corpora  cavernosa.  A  more  frequent  com- 
plication of  gonorrhoea  is  inflammation  of  the  glans  penis  ihalanitis)  and 
of  the  prepuce  {post7i/tis),  due  not  only  to  the  mechanical  effects  of  the 
39 


610  A  TEXT-BOOK   ON   SURGERY. 

discharge,  but  to  diiect  iuvasiuu  by  contagion.  As  a  result  of  such 
extensive  infiltration,  the  penis  is  subjected  to  various  deformities,  pain- 
ful in  an  extreme  degree,  and  not  without  danger  to  the  integrity  of  this 
organ. 

Chordee,  or  bowing  of  the  penis,  is  a  c<iuiiii(iu  symptom.  Tlic  (H'giui 
is  in  part  or  wholly  erected,  and  on  account  of  the  iniiitiation  of  the 
vascular  spaces  of  tlie  corpus  spongiosum  with  the  embryonic  inllamma- 
tory  tissue,  it  fails  to  expand  with  the  corpora  cavernosa. 

Balano-postJiitis,  in  the  case  of  a  long  and  tightly  litting  prepuce, 
becomes  at  times  an  annoying  if  not  a  serious  complication.  Complete 
'phimosis  may  occur  as  a  result  of  the  swollen  condition  of  the  prepuce, 
or,  when  the  foreskin  is  slipped  behiiul  the  corona  glandis,  parapJiimosis 
may  ensue.     If  not  relieved,  gangrene  in  most  cases  is  imminent. 

These  complications  are  as  a  rule  a  part  of  the  second  stage  of  gonor- 
rhoea, occui'ring  within  the  first  eighteen  days  of  an  attack,  and  gi-adually 
disn])peariug  during  the  third  stage. 

I'ntliology. — Strictly  speaking,  the  morbid  process  is  an  inflammation 
of  the  mucous  membrane  of  the  urethra  and  the  submucous  connective 
tissue.  The  extensicm  to  other  organs  is  purely  accidental.  It  com- 
mences at  the  meatus  and  travels  backward.  The  epithelium  is  swollen, 
there  is  marked  hypereemia  of  the  submucous  tissue,  ^vith  the  escape  of 
leucocytes  and  the  formation  of  the  common  embryonic  tissue  of  inflam- 
mation. In  milder  cases  the  products  of  inflammation  undergo  retro- 
gressive changes,  and  are  absorbed  ;  while  in  other  instances  connective- 
tissue  development  is  precipitated,  ending  in  cicatrization  and  the  forma- 
tion of  stricture.  The  organic  elements  of  gcmorrhoeal  pus  are  leucocytes, 
embryonic  cells,  epithelia,  and  blood-corpuscles. 

The  diagnosis  of  specific  urethritis  may  be  made  out  from  the  suc- 
cession of  symptoms  given.  It  can  rarely  be  mistaken.  It  is  at  times 
necessary  to  difi'erentiate  gonorrhoea  from  simple  or  non-specific  urethri- 
tis. The  latter  disease  lacks  every  symptom  of  virulence  which  is  char- 
acteristic of  the  former.  Within  the  first  few  days  of  an  attack  it  is  not 
idways  easy  to  make  a  positive  diagnosis,  but  after  the  first  week  is  passed 
the  symptoms  are  evident. 

Treatment. — Gonorrhoea  is  a  self-limited  disease,  running  a  given 
cour.se,  and  unde-r  favorable  conditions  ending  in  recovery  without  the 
aid  of  medication. 

Efforts  to  abort  the  disease  by  the  injection  of  corrosive  su])stances 
are  not  justifiable.  Any  substance  capable  of  destroying  the  virus  of 
gonorrhoea  is  also  capable  of  doing  damage  to  the  urethra,  more  serious 
in  its  consequences  than  those  of  the  worst  forms  of  the  disease  left  witli- 
out  medical  interference. 

When  specific  nrethritis  is  recognized  in  its  earlier  stages,  the  pa- 
tient should  be  impressed  with  the  importance  of  rest,  and  the  regu- 
lation of  his  diet  and  manner  of  living.  It  is  important  that  the  danger 
of  inoculation  of  the  conjunctiva,  or  other  raucous  surfaces,  with  the 
virus,  should  be  emphasized.  If  necessity  compels  the  patient  to  take 
the  increased  risk  which  exercise  implies,  the  physician  should  relieve 


SPECIFIC  URETHRITIS.  611 

himself  of  this  much  of  responsibility  by  insisting  upon  the  minimum 
of  physical  exertion.  The  diet  should  be  nutritious,  yet  simple,  and 
stimnlatinu:  beverages,  as  coffee  and  the  alcoholic  group,  should  l»e  for- 
bidden. Tea  is  not  so  objectionable  as  coffee,  except  when  it  induces 
sleeplessness.  The  bowels  should  be  kept  open  by  the  use  of  fruits  and 
the  administration  of  the  mild,  laxative  waters.  The  administration  of 
citrate  of  potash,  in  doses  of  grs.  xx,  four  or  five  times  a  day,  will  have  a 
beneficial  effect  upon  the  urine  and  the  urethra.  It  may  be  conveniently 
taken  in  a  glass  of  water  to  which  the  juice  of  half  a  lemon  has  been 
added.  A  hip-bath  in  warm  water  every  night  and  morning  not  only 
insures  a  degree  of  cleanliness  which  is  desirable,  but  is  not  without  value 
as  an  antiphlogistic. 

In  addition  to  these  general  features  of  treatment  to  be  carried  out 
during  the  first  and  second  stages  of  gonorrhoea,  certain  local  measures 
are  equally  imj^ortant.  One  of  the  chief  of  these  is  to  secure  free  dis- 
charge of  the  pus  from  the  urethra  and  prepiace.  The  penis  should  be 
kept  i)endent,  and,  if  possible,  the  prepuce  worn  so  as  to  leave  the  gland 
exposed.  The  common  practice  of  stuffing  a  piece  of  lint  or  a  tuft  of 
absorbent  cotton  over  the  meatus  and  beneath  the  prepuce,  and  then 
pressing  the  foreskin  over  this  to  hold  the  plug  in  jjlace,  tbus  stopping  up 
the  urethra  when  free  drainage  is  essential,  and  holding  the  acrid  dis- 
charge in  contact  with  the  glans  and  prepuce  when  these  should  be  pro- 
tected, is  exceedingly  objectional)le.  Scarcely  less  so  is  the  habit  of 
tying  rags,  lint,  or  cotton  about  the  j^enis,  for  these  dressings  interfere 
with  the  circulation  in  this  organ. 

A  bag  of  oiled-silk,  rubber  tissue,  or,  if  these  can  not  be  obtained,  of 
ordinaiy  cloth,  should  be  made  large  and  long  enough  to  fit  loosely  over 
the  penis.  It  is  held  in  place  by  strings  which  pass  up  to  a  belt  worn 
around  the  waist.  A  pellet  of  absorbent  cotton  in  the  bottom  of  this  bag 
suffices  to  catch  the  pus  which  drips  from  the  meatus.  It  is  usually 
necessary  to  have  two  of  these  bags,  for  purposes  of  cleanliness.  The 
various  complications  of  gonorrhoea,  as  cystitis,  prostatitis,  epididymitis, 
orchitis,  etc.,  have  been,  or  wUl  be,  considered  under  their  respective 
heads. 

For  the  control  or  relief  of  chordee  the  following  rule  of  practice  will 
suffice  :  The  patient  should  be  advised  to  refrain  from  sleeping  on  the 
back,  and  should  be  directed  to  empty  his  bladder  at  more  frequent  in- 
tervals than  ordinary.  When  the  attack  is  precipitated,  standing  with 
the  naked  back  in  contact  with  the  wall,  or  s(mie  cold  surface,  will  often 
cause  the  erection  to  disappear.  The  same  may  be  said  of  the  local  use 
of  ice  or  cold  water.  A  full  dose  of  bromide  of  potassium  and  chloral- 
hydrate  at  bedtime,  and  repeated  at  intervals,  if  necessary,  is,  however, 
the  surest  way  to  control  the  more  annoying  and  obstinate  cases. 

Injections  of  the  uretlira  in  gonorrhoea  should  be  made  with  great 
care.  They  are  contraindicated  in  the  acute  inflammatory  and  suppu- 
rative stages  of  this  disease.  Usually,  from  the  tenth  to  the  twentieth 
day  after  suppuration  is  noticed,  if  the  foregoing  measures  have  been 
faithfully  carried  out,  the  character  of  the  discharge  is  chauged  from  the 


612  A  TEXT-BOOK   ON  SURGERl. 

yelknv,  thick,  and  profuse  pus  of  acute  fz;()norih(i'u,  to  the  scant,  whitish, 
milky  fluid  of  the  later  stages  of  the  inflammation,  and,  with  this,  the 
painful  symptoms  have  also  disappeared.  It  is  not  until  tins  period  is 
reached  that  the  use  of  an  injection  should  be  entertained.  IS'itrate  of 
silver,  locally  applied,  possesses  more  curative  properties  than  any  other 
a.ijent,  but  it  is  objecti(mable  on  account  of  the  discoloration  it  protluces. 
The  injection  which  is  least  objectionable  is  composed  of  acetate  of  zinc 
in  dilute  solution  of  subacetate  of  lead.     From  gr.  j  to  iij  of  the  zinc 

may  be  used  to  §j  of 
the  lead  solution.  The 
weaker  preparation  is  in 
general  to  be  preferred. 

Fio.  G14.— The  proper  s.vriiif,'e  lor  gonorrhoea.  '^"^      Uretlll'al       Syringe 

should  be  selected  with 
great  care.  Fig.  614  represents  a  proper  instrument.  It  contains  about 
3ij,  has  a  conical  nozzle,  and  can  be  used  with  one  hand.  The  long-noz- 
zled,  pointed  syringe  should  never  be  emjjloyed.  In  its  use  the  i)oint 
strikes  against  the  mucous  membrane,  causing  an  exaggeration  of  the  in- 
flammatory process  at  this  point,  not  infrequently  resulting  in  strictui-e. 
An  injection  should  be  performed  as  follows,  and  each  })atient  should 
be  thoroughly  schooled  before  he  is  intrusted  with  its  emj^loyment  upon 
himself:  The  bladder  should  not  he  emptied.  The  bottle  containing  the 
injection-fluid  should  be  shaken,  and  a  quantity  sufficient  to  lill  the 
syringe  twice  emptied  into  a  cup,  and  drawn  into  the  instrument  as 
needed.  The  syringe  is  now  held  with  the  point  u]iward,,  and  the  piston 
pushed  up  until  the  air  which  may  have  entered  with  the  fluid  is  expelled. 
A  small  quantity  of  oil  or  vaseline  is  rubbed  upon  the  tip  of  the  syringe, 
the  i)atient  lies  ui^on  his  back,  the  glans  penis  is  held  between  the  Angers 
of  the  left  hand,  and  the  index-finger  is  carried  through  the  ring  on  the 
end  of  the  piston,  while  the  cylinder  is  grasped  between  the  thumb  and 
middle  finger.  The  conical  end  of  the  syringe  is  now  introduced  into  the 
meatus,  and  pressed  in  with  sufficient  firmness  to  prevent  the  escape  of 
the  fluid  while  the  contents  of  the  cylinder  are  slowly  emjitied  into  the 
urethra.  With  a  syringe  of  this  capacity  there  is  little  danger  of  over- 
coming the  resistance  of  the  compressor-muscle,  and  thus  forcing  the 
injection-material  back  into  the  bladder.  Should  this  accident  occur,  the 
urine  which  is  in  this  organ  will  dilute  the  zinc  so  freely  that  its  irritating 
jjroperties  will  be  lost.  In  making  an  injection  the  urethra  should  be 
well  distended,  so  that  all  parts  of  the  mucous  surface,  as  well  as  the  fol- 
licles, may  be  brought  in  contact  with  the  fluid.  After  holding  the  injec- 
tion in  the  urethra  for  from  one  to  three  minutes  it  may  be  allowed  to 
run  out,  and  the  patient  directed  to  empty  his  bladder.  A  second  quan- 
tity, about  one  thii-d  less  than  the  first,  is  again  injected.  These  injec- 
tions should  be  repeated  night  and  morning,  and,  if  convenient,  at  noon. 
Upon  the  supervention  of  any  marked  symptoms  of  irritation,  as  cystitis 
or  an  increase  of  the  urethral  inflammation,  or  epididymitis,  etc.,  they 
should  be  immediately  discontinued.  The  period  in  the  history  of  a 
gonorrhoea  when  internal  medication  may  be  used  with  advantage  varies 


BALANITIS.  613 

from  the  third  to  the  fifth  week  of  the  disease.  In  the  acute  stages, 
while  the  inflammatory  symptoms  are  prominent,  they  are  contraindi- 
cated.  The  oil  of  sandal-wood  and  balsam  of  copaiba  are  the  more  useful 
remedies  of  this  class.  The  f(jrnier,  in  doses  of  five  to  ten  drops,  fr.jm 
live  to  ten  times  a  day,  is  more  readily  borne  by  the  stomach,  and  does 
not  cause  the  rash  which  not  infrequently  follows  the  administration  of 
copaiba.  These  remedies,  liowever,  very  often  can  not  be  taken,  and 
should  not  be  persisted  in  when  they  interfere  with  the  functions  of  the 
stomach.  Even  when  thus  carefully  managed,  the  annoying  symptoms 
of  gonorrhoea  continue  for  from  four  to  eight  weeks,  and  in  most  cases 
there  is  a  slight  watery  or  mucous  discharge  for  several  weeks  after  the 
case  passes  out  from  the  immediate  notice  of  the  practitioner.  Upon  the 
whole,  the  effect  of  treatment  upon  the  duration  of  this  disease  is  not 
entirely  satisfactory. 

Among  the  unpleasant  complications  of  gonori-hcea  are  balanitis,  pos- 
thitis, paraphimosis,  prostatitis,  cystitis,  epididymitis,  orchitis,  bubo, 
ophthalmia,  and  retention  of  urine. 

Balanitis  and  posthitis,  inflammation  of  the  glans  and  prepuce,  are 
conditions  existing  in  a  varying  degree  in  almost  all  cases  of  gonorrhaui. 
Among  the  cii'cumcised,  f)r  those  with  short  and  retracted  foreskins, 
posthitis  need  not  occur,  but  the  acrid  discharge  will  always  afl'ect 
the  epithelial  covering  of  the  glans  in  the  immediate  neighborliood  of 
the  meatus.  When  the  foreskin  is  long  and  adherent,  or  not  leadily 
drawn  behind  the  glans,  it  usually  becomes  swollen  and  tense,  retains 
the  irritating  discharge,  and  inaugurates  an  exceedingly  painful  and 
annoying  condition  of  phimosis.  Even  when  thus  swollen,  if  the  pre- 
puce can  be  retracted,  it  is  apt  to  be  caught  liehind  the  corona  and 
become  irreducible,  with  ensuing  strangulation,  if  not  relieved  by  oper- 
ative interference.  Preputial  sloughing  will  occur  in  a  certain  propor- 
tion of  neglected  cases. 

In  the  treatment  of  gonorrhcoa  certain  measures  were  detailed  looking 
to  the  pi-evention  of  these  complications.  When,  however,  they  are 
present  in  a  mild  degree,  balanitis  and  posthitis  disappear  with  proper 
attention  to  cleanliness.  The  glans  and  prepuce  should  be  irrigated  by 
being  submerged  in  a  vessel  of  warm  water.  Soap  should  not  be  em- 
ployed. The  hip-bath,  already  given  as  useful  in  the  general  management 
of  the  disease,  is  especially  so  in  this  complication. 

The  inflammatory  phimosis  of  gonorrlujea,  as  of  non-specific  halano- 
postliitis,  demands  active  measures  of  treatment.  In  milder  cases  it  may 
suffice  to  maintain  cleanliness  by  the  frequent  sub-preputial  injection  of 
tepid  water.  For  this  purpose  a  syringe  with  a  delicate  dull  point  or 
nozzle,  about  an  inch  in  length,  is  needed.  It  should  be  oiled,  carefully 
introduced  between  the  glans  and  prepuce,  and  the  contents  slowly  dis- 
charged. An  irrigating  apparatus  may  also  be  attached  to  the  nozzle, 
and  a  continuous  current  applied,  which  does  away  with  the  irritation  of 
repeated  introductions  of  the  nozzle.  If  these  milder  measures  do  not 
relieve  tlie  pain,  tension,  and  tlirc^atenod  strangulation,  an  incision  slutuld 
be  made.     The  prepuce  may  be  nicked  in  several  jdaces,  or  a  director 


(U-t 


A  TEXT-BOOK   ON   SURGERY. 


introduced  in  tlie  median  line  above,  along  the  groove  of  wliicli  a  bistoury 
is  carried,  and  the  division  effected. 

When  intlaniniatory  ])ara]iliinio.sis  exists,  adhesions  ra]tidly  occur  at 
a  point  just  behind  the  corona,  on  the  dorsnni  penis,  rendcj'ing  a  reduc- 
tion impossible  unless  these  ti-ansverse  bands  are  divided.  The  reduc- 
tion of  a  paraphimosis  is  undertaken  in  this  manner:  The  organ  is  held 
in  a  vessel  of  cold  water  for  a  few  minutes,  or  cold  cloths  are  wra])ped 
loosely  pver  and  around  the  swollen  parts.  When  removed,  the  glans 
and  prepuce  are  thoroughly  lubricated,  and  the  organ  grasped  so  that 
while  the  soft  parts  of  the  thumbs  jiress  the  glans  backward,  the  iingera 
are  drawing  the  prepuce  to  the  front.  Or  the  i)enis  may  be  grasped 
by  the  thumb  and  linger  of  the  left  hand,  and  the  foreskin  drawn  for- 
ward while  the  glans  is  pushed  backward  by  the  thumb  and  fingers  of 
the  opposite  meml)er.  When  the  reduction  is  accomplished,  the  patient 
should  be  directed  to  make  every  effort  to  prevent  a  recurrence  of  the 
accident. 

If  the  efforts  at  reduction  fail,  the  contractions  on  the  dorsum,  behind 
the  glans,  should  be  divided  by  one  or  more  incisions  in  the  long  axis  of 
the  penis.  OCdema  of  the  prepuce,  especially  of  the  lower  portion,  is  apt 
to  occur,  even  in  cases  of  recent  paraphimosis,  and,  when  the  condition 
has  existed  for  a  day  or  two,  infiltrations  occur,  which  may  persist  for  a 
long  time  after  the  constriction  is  relieved. 

Prostatitis  and  cystitis,  occurring  with  gonorrhopa,  require  treatment 
not  differing  from  that  already  given.  Retention  must  be  relieved  by 
the  small  soft  catheter,  or  by  supra-pubic  aspiration.  Epirlirhjmitis,  or 
inflammation  of  the  vas  deferens  and  the  globus  major  and  minor,  is  one 
of  the  most  painful  complications  of  gonorrhoea.  Perfect  physical  quiet, 
with  siipport  of  the  scrotum  and  testicle,  are  essential.  The  last  of  these 
measures  may  be  secured  by  using  the  handkerchief  sling,  which  is  made 
as  follows : 

Attach  a  belt  or  piece  of  roller  around  the  waist,  above  the  pelvis ; 
fold  a  good-sized  silk  handkerchief  in  a  triangular  shape,  carry  the  cen- 
ter of  the  long  side  of  this  tri- 
angle beneath  the  scrotum,  at 
the  perineo-scrotal  junction, 
attach  one  of  the  long  ends  to 
the  belt,  near  the  anterior  su- 
perior spine  of  the  ilium,  on 
either  side,  and  bring  the 
short  piece  directly  upward, 
in  front  of  the  scrotum  and 
penis,  and  pin  it  to  the  belt 
in  the  median  line  ;  or  the 
ends  may  be  tied  just  above 
the  root  of  the  penis  (Figs. 
615,  616). 
Another  method  is  to  i)lace  a  three-cornered  cushion  beneath  the 
scrotum,  close  up  to  the  jierinseum,  and  allow  the  testicles  to  rest  upon 


; 

Fig 

Handkerchief  suspensory 


C15. 


Fiu.  616. 
(After  HUl.) 


EPIDIDYMITIS  AND   ORCHITIS.  615 

this  support ;  or  two  thickly  folded  towels  may  be  pinned  together  and 
carried  tightly  around  the  thighs,  at  the  level  of  the  perinjpum. 

At  times  the  tension  of  the  parts  is  so  great  that,  not  only  to  relieve 
pain,  but  to  i^revent  suppuration  or  possible  gangrene,  puncture  or  in- 
cision is  imperative.  The  most  immediate  relief  will  follow  this  opera- 
tion. A  sharp  narrow  blade  is  preferable,  and,  if  the  instrument  is  not 
made  for  this  especial  purpose,  it  may  be  extemporized  l)y  projecting  the 
point  of  an  ordinary  sharp-pointed  bistoury  half  an  inch  beyond  the 
surface  of  a  cork  through  which  the  knife  is  thrust.  With  this  guard 
attached,  the  punctures  may  be  made  rapidly  and  without  danger  of 
penetrating  too  deeply. 

Although  the  procedure  is  very  painful,  it  is  usually  so  ra]tidly  ac- 
complished that  an  anaesthetic  is  not  necessary.  The  injection  of  a  2-per- 
cent cocaine  solution  will  afford  a  fair  degree  of  anaesthesia.  The  opera- 
tor holds  the  scrotum  and  testicle  so  as  to  make  tense  the  skin  over  the 
epididymis  and  to  expose  it  properly  to  view,  and  then  by  well-directed 
and  rapid  thrusts  punctures  the  organ  in  from  two  to  four  or  six  points, 
scattered  over  the  induration.  A  free  discharge  of  dark  or  black  l)lood 
usually  follows,  and  in  from  twenty  to  thirty  minutes  the  pain  is  greatly 
if  not  entii-ely  relieved.  The  antiseptic  precautions  should  be  carried 
out  in  this  procedure. 

Partial  or  complete  orcMtis  is  not  infrequent  in  gonorrhoea  with  epi- 
didymitis. The  treatment  is  in  general  similar  to  that  of  the  last-named 
disease.  The  diagnosis  is  readily  made  out  by  the  touch,  for,  when  hy- 
drocele does  not  coexist,  the  induration  of  the  organ  can  not  well  be 
mistaken.  Poultices  of  tobacco  have  long  enjoyed  a  reputation  in  the 
treatment  of  orchitis  and  epididymitis,  but  when  warm  applications  are 
indicated,  well-saturated  and  frequently  changed  warm  cloths  will  be 
found  equally  satisfactory  in  the  effect  produced,  and  much  more  cleanly 
than  the  poultices.  In  the  majority  of  instances^  cold  will  be  more  agree- 
able than  heat.  The  ice-bag  may  be  utilized  in  the  following  manner  with 
great  satisfaction :  A  bladder  or  rubber  bag  is  filled  with  crushed  ice, 
placed  upon  the  three-cornered  perineal  cushion,  and  the  inflamed  organ 
allowed  to  rest  upon  it.  If  the  cold  is  too  great  for  comfort  (and  the 
patient  may  usually  be  relied  upon  to  determine  this),  a  layer  or  two  of 
lint  or  cotton  may  be  interposed.  It  occasionally  becomes  necessary 
to  puncture  or  incise  the  tunica  albngiiiea  in  orchitis  somewhat  after 
the  fashion  given  in  puncture  for  epididymitis.  Two  methods  are  em- 
ployed, namely:  to  carry  a  sharp-pointed,  long  knife  through  a  single 
puncture  of  the  scrotum  down  to  the  testicle,  and  incise  the  fibrous  cap- 
sule in  one  or  more  places  parallel  with  its  long  axis  and  along  its  an- 
terior surface  ;  or  to  use  an  instrument  similar  to  that  employed  in  epi- 
didymitis, and  make  several  pimctures  through  the  scrotum  and  the 
anterior  portion  of  the  capsule. 

IiKjiiinal  adinltis,  or  biiho,  occurs  in  a  considerable  proportion  of 
cases  of  specific  urethritis,  and  is  apt  to  be  bilateral.  The  disease  is 
readily  recognized  by  the  swelling  in  the  groin.  The  inflammatory 
process  is  usually  so  rapid  in  its  invasion  that  the  different  glands  in 


616  A  TEXT-BOOK   ON   SURGERY. 

this  jjroiii)  of  lymphatics  can  not  ])e  made  out,  the  entire  group  being 
matted  together  in  one  mass  of  embryonic  cells  infiltrating  the  tissues 
around  the  glands  as  well  as  involving  their  substance.  The  goiioirlupal 
bubo  tends  naturally  to  suppuration.  In  mild  cases,  and  where  the 
proper  measures  are  taken  at  the  early  appearance  of  the  adenitis,  this 
disaster  may  be  averted  ;  but  in  others,  i)art]y  owing  to  tlie  nnfavoi-ible 
condition  of  the  tissues  and  to  the  continued  irritation  from  motion,  pus- 
formation  can  not  be  prevented. 

In  the  treatment  of  acute  intlamuiatoi'y  liubo,  perfect  rest  is  impera- 
tive, and  the  dorsal  deculntus  should  be  maintained.  Local  medicath)n 
is  of  little  value.  The  employment  of  cold  will  be  found  agreeable  in 
the  earlier  stages,  and  may  serve  to  prevent  suppuration.  Tlie  ice-bag 
may  be  employed  by  laying  it  upon  a  cii'cular  pad  placed  around  the 
bubo.  In  this  way  the  pressure  is  entirely  taken  off  the  inllamed  sur- 
face. After  the  formation  of  pus  is  inevitable,  warm  cloths  or  poultices 
should  be  sxibstituted.  When  pus  is  formed,  a  free  incision  under  co- 
caine anjesthesia  should  be  made. 

CJironic  suppurative  adenitis  of  the  inguinal  glands  occasionally  per- 
sists long  after  the  gcmorrhopa  which  caused  it  has  disappeared.  The 
only  remedy  is  to  dissect  out  the  diseased  glands  with  the  curved  scis- 
sors, or  scrape  them  out  with  Volkmann's  spoon. 

iynnovv\\(Sii\  proctitis  is  a  rare  affection,  and  does  not  call  for  especial 
consideration. 

Op?dhalmia,  resulting  from  the  inoculation  of  the  conjunctiva  with 
the  virus  of  specific  urethritis,  has  been  considered  with  lesions  of  the  eye. 

Gonorrheal  Blieumatism. — In  a  certain  proportion  of  individuals 
suffering  from  gonori'hoeal  inoculation  at  a  period  varying  from  five  or 
six  days  to  several  weeks  from  the  date  of  the  attack,  symptoms  not  un- 
like those  occurring  in  gout  or  rheumatism  make  their  appearance  in 
the  joints,  tendons,  and  bursae,  and  less  frequently  in  the  nei-ves  and 
eye.  The  parts  involved  become  more  or  less  swollen  and  painful.  The 
pain,  however,  is  less  than  in  ordinary  rheumatism.  The  felirile  move- 
ment is  not  high,  and  the  character  of  the  urine  is  unchanged,  in  both 
of  which  features  it  differs  from  ordinary  rheumatism  (Fournier).  Neu- 
ralgia occasicmally  supervenes  in  the  course  of  this  disease.  In  a  certain 
proportion  of  cases  the  eye  is  affected,  but  the  ophthalmia  here  in  no 
ways  resembles  that  of  gonorrhoea!  conjunctivitis.  The  pathology  of 
this  disease  is  not  understood,  and  the  treatment  is  entirely  expectant. 

Gonorrhoea  in  females  is  usually  less  severe  than  with  males,  and 
yields  more  readily  to  treatment.  The  chief  seat  of  the  inflammation  is 
in  the  vagina.  The  urethra  and  bladder  may  also  become  involved.  In 
the  treatment,  quiet  is  of  first  importance.  The  warm  hip-bath  should 
be  employed  several  times  a  day,  and  the  vagina  iirigated  at  regular  in- 
tervals with  warm  water  thrown  in  from  a  fountain-syringe.  As  soon 
as  the  acute  symptoms  have  subsided,  injections  of  dilute  subacetate  of 
lead,  with  acetate  of  zinc  (grs.  ij-iv  to  3  j),  should  be  employed. 

Simple  Urethritis. — There  is  occasionally  met  with  in  practice  an 
acute  inflammation  of  the  urethra,  attended  by  a  slight  muco-ijurulent 


THE  URETIIRA— GLEET.  617 

discharge,  in  patients  who  have  not  been  subjected  to  the  specific  con- 
tagion of  gonorrhoea.  It  is  well  established  that  urethritis  in  the  male 
may  be  caused  by  exposure  to  cold,  and  by  the  irritation  of  a  vaginal 
or  uterine  discharge  in  a  woman  not  affected  with  gonorrhoea.  Simple 
urethritis  differs  in  many  respects  from  tlie  specific  disease.  In  color, 
the  pus  is  white,  and  in  consistency  it  is  thinner,  and  resem])les  rather 
the  discharge  of  gleet.  The  itching^  or  burning  sensation  of  tlie  more 
violent  affection,  if  not  entirely  absent,  is  much  less  annoying  in  simjjle 
urethritis. 

Chordee,  epididymitis,  orchitis,  and  cystitis  are  rarely  present,  and, 
when  occurring,  are  milder  in  degree  than  when  these  affections  compli- 
cate a  gtmorrhoea.  The  history  of  the  disease  is  short,  even  when  left 
without  treatment.  In  the  treatment  of  simple  urethritis,  mild  astrin- 
gent injections  are  usually  indicated  in  the  earlier  stages  of  the  inflam- 
mation, unless  the  process  is  more  than  ordinarily  violent,  under  which 
conditions  the  measures  advised  for  the  first  stage  of  specific  urethritis 
should  be  adopted.  The  warm  hip-bath  should  be  advised,  and  alkaline 
drinks  administered.  Dilute  subacetate  of  lead,  1  j,  with  acetate  of  zinc, 
gr.  j,  will  be  about  the  proper  strength  for  the  injection.  The  oil  of 
sandal-wood  should  be  given  after  the  fourth  or  fifth  day.  The  duration 
of  simple  urethritis  varies  from  three  or  four  days  to  two  weeks. 

Gleet,  or  Chi'onic  Urethritis. — Gleet  is  a  name  given  to  the  prolonged 
discharge  from  the  urethra  of  a  variable  quantity  of  muco-i»urnlent, 
bluish-white  fluid.  This  discharge  is  a  transudation  from  the  mucous 
and  glandular  epithelia  of  the  urethra.  In  gleet,  all  or  any  limited 
portion  of  this  tube  may  be  affected.  The  pathological  change  is  a  puf- 
finess  of  the  lining  membrane,  due  to  hypersemia  of  the  sub-ei)ithelial 
vascTilar  area,  with  a  tendency  to  embryonic  and  connective-tissue  for- 
mation. In  some  points  patches  of  erosions  or  tissue-necrosis  occur. 
The  epithelia  lining  the  glandular  apparatus — as  those  of  the  prostate, 
Cowper's  glands,  and  the  urethral  follicles — become  more  or  less  in- 
volved. Not  infi-equently  the  outlets  to  these  follicles  become  ob- 
striicted  by  the  supei'ficial  inflammatory  process,  i-esulting  in  the  forma- 
tion of  one  or  more  retention- cysts,  which  project  into  the  lumen  of 
the  tube. 

Any  form  of  acute  urethritis  may  pass  into  this  chronic  condition  of 
gleet,  or  a  urethritis,  subacute  in  its  character  from  the  beginning,  may 
continue  as  a  gleet. 

Although  chronic  urethritis  may  exist  without  the  pre.sence  of  strict- 
ure of  the  urethra— as  in  follicular  urethritis— the  exceptions  to  this 
rule  are  extremely  rare.  Any  chronic  interference  with  the  normal  cali- 
ber of  the  urethra  serves  to  induce  a  catarrhal  condition  of  the  mucous 
membrane  of  this  canal,  which,  commencing  near  the  seat  of  stricture, 
may  involve  any  portion  of  the  tube. 

The  treatment  of  gleet  involves,  primarily,  the  removal  of  the  cause. 
Taking  stricture  as  the  chief  cause,  urethrotomy  with  dilatation,  or  dila- 
tation without  cutting,  is  demanded.  In  mild  cases  without  dose  organic 
stricture,  the  introduction  of  the  steel  sound  will  often  effect  a  cure. 


618  A  TEXT-BOOK  ON   SURGERY. 

The  methods  of  i)rucedure  w  ill  be  given  in  full  iu  the  treatment  of  strict- 
ure of  the  urethra. 

In  rlironic  follicular  nrctliritis  a  most  excellent  method  of  treatment 
is  the  application  of  cold  by  means  of  the  double  ck)sed  silver  catheter 

(Fig.  617).     This  instru- 
^  ment    has    the    ordinary 

"  curve  of  the  male  cathe- 
ter, is  hollow,  with  o  cen- 
tral partition  which  does 

i'lo.  (il7.— Uoubk-currcut  closed  catheter  lor  applying  V^nX,    Ouite    extend    tO    the 

cold  to  the  urethra.  1 

tip,  and  it  is  completely 
closed,  so  that  the  water 
passes  down  one  side  and  up  the  other  without  coming  in  contact  with 
the  mucous  membrane. 

It  is  advisable  to  emi)loy  a  catheter  large  enough  to  fairly  distend 
the  urethra.  Nos.  14,  16,  and  18  (U.  S.  scale)  will  be  more  generally 
useful.  It  should  be  oiled  and  introduced  as  far  back  as  the  i)ros- 
tatic  urethra.  A  rubber  tube  leading  from  an  irrigator  filled  with 
cracked  ice  and  water  is  attached  to  one  of  the  two  outer  mouths  of  the 
catheter.  A  second  tube  is  fastened  to  the  other  opening  and  leads  into 
a  basin.  The  water  is  turned  on  slowly  at  first,  and  is  allowed  to  run 
in  from  five  to  ten  minutes,  and  the  catheter  is  tlien  removed.  The 
sensation  is  slightly  painful  for  a  few  seconds,  but  anaesthesia  soon  su- 
pervenes. The  operation  may  be  repeated  in  from  three  to  six  days. 
If  the  reaction  is  severe,  the  interval  may  be  longer  between  the  appli- 
cations 

Stricture  of  tlie  Male  Uretlira. — Strictures  of  the  urethra  may  be  di- 
vided into  two  classes :  true  or  organic,  and  false  or  spasmodic. 

A  diminution  of  the  caliber  of  this  canal,  as  a  result  of  an  inflamma- 
tory process,  constitutes  a  true  or  organic  stricture.  A  spasmodic  strict- 
ure exists  when  the  normal  caliber  is  diminished  as  a  result  of  contrac- 
tion of  the  voluntary  or  involuntary  muscular  elements  connected  with 
the  urethra.  Congenital  non-inflamnuitory  narrowing  of  the  meatus 
does  not  constitute  a  stricture.  The  normal  contraction  of  the  com- 
pressor-u  ret  hne  or  "cut-off  "muscle  is  also  excluded  in  the  definiti(m  of 
spasmodic  sti'icture. 

An  organic  stricture  may  be  lateral,  annular,  or  tortuous. 

In  lateral  stricture  the  entire  circumference  of  the  urethral  cylinder 
is  not  involved,  the  cicatricial  contraction  being  contined  to  a  limited  arc 
of  the  circle.  It  is  comparatively  rare.  In  annular,  or  ring  stricture, 
the  cicatricial  contraction  involves  the  entire  circumference.  It  may 
vary  in  width  from  a  line  to  one  inch.  In  tortuous,  or  irregular  stricture, 
an  inch  or  more  of  the  urethral  canal  is  involved.  Two  or  more  annular 
or  lateral  strictures  may  unite  to  form  a  tortuous  or  irregular  strictiire. 

The  pathology  of  stricture  of  the  urethra  is  that  of  an  inflammation 
of  variable  intensity  involving  the  epithelial  and  submucous  basement 
membrane  of  this  canal,  together  with  the  deeper  tissues  of  the  corpus 
spongiosum,  and  occasionally  of  the  corpora  cavernosa.     This  jirocess 


THE  URETHRA— STRICTURE.  619 

usually  begins  from  within,  but  may  originate  in  the  deeper  tissues  of 
the  penis  and  involve  the  urethi-a  secondarily. 

In  a  typical  case  there  is  first  an  increased  vascularity  of  the  submu- 
cous area,  followed  by  emigration  of  leucocytes  and  cell-proliferation. 
The  lining  membrane  becomes  puffy  and  swollen,  and  the  diameter  of 
the  canal  is  diminished.  As  the  acute  inflammation  subsides,  the  pufii- 
ness  disappears,  but  the  caliber  of  the  tube  is  again  diminished  by  the 
contraction  which  takes  place  in  the  newly  formed  connective-tissue  ele- 
ments (cicatrization). 

Causes. — Among  the  causes  of  stricture,  specific  urethritis  ranks  first, 
and  it  is  highly  probable  that  the  precedence  which  gonorrhoea  enjoys 
in  the  jetiology  of  stricture  is  due  rather  to  the  improper  management 
of  the  urethritis  than  to  the  effects  of  the  inflammation  proper.  The 
employment  of  corrosive  and  irritating  injections,  the  introduction  of 
instruments  (syringe-nozzles,  bougies,  etc.)  upon  an  inflamed  surface,  to- 
gether with  the  unnecessary  exposure  of  the  person  in  the  uninterruisted 
pursuit  of  business  or  pleasure,  combine  to  make  gonorrhoea  one  of  the 
most  dangerous  of  the  venereal  diseases. 

Any  violence  inflicted  ujjon  the  urethra,  either  from  without,  as  by  a 
blow  upon  the  perinajum  or  penis,  or  from  within,  as  by  the  reckless 
use  of  instruments,  the  lodgment  of  calculi  or  other  foreign  bodies,  may 
also  cause  a  stricture. 

Chancroidal  ulcer  within  the  meatus  is  a  rare  cause  of  this  lesion. 
Certain  medicines,  as  cantharides,  if  administered  in  large  doses  and  for 
a  prolonged  period,  induce  inflammation  of  the  ui'inary  tract,  and  thus 
may  cause  stricture. 

Location. — The  most  freqiient  seat  of  organic  stricture  is  in  that 
portion  of  the  urethra  limited  behind  l\y  the  compressor-urethrse  mus- 
cle, and  in  front  by  the  susi)ensory  ligament  at  the  junction  of  the  penile 
with  the  perineal  urethra.  Next  in  order  is  the  first  inch  within  the 
meatus.  Stricture  in  the  prostatic  portion  is  rare.  As  stated  in  the 
consideration  of  diseases  of  the  prostate,  it  may  occur  in  general  hyper- 
trophy of  this  organ. 

Diagnosis. — The  symptoms  of  strictiire  are  a  gleety  discharge,  inter- 
ference with  the  escape  of  urine  or  semen,  and  pain.  A  muco-purulent 
discharge  continuing  for  several  months  is  almost  pathognomonic  of  this 
lesion,  and  justifies  exploration  in  order  to  determine  the  presence  of 
stricture.  Interference  with  the  escape  of  urine  from  the  bladder  when 
at(my  of  this  organ  and  hypertrophy  of  the  prostate  are  eliminated,  are 
also  symptoms  of  importance.  A  twisted  or  forked  stream,  when  not  of 
diminished  volume,  has  no  significance,  for  this  may  exist  with  a  per- 
fectly normal  canal.  Pain  is  not  often  a  symptom  of  organic  stricture, 
but,  when  present,  is  not  without  value  as  an  indication  of  localized  in- 
flannuation. 

No  matter  what  symjitoms  may  exist,  a  diagnosis  can  f)nly  be  arrived 
at  by  instrumental  exploration,  which  can  be  done  ^vithout  pain,  and 
by  which  means  the  exact  location  and  character  of  the  stricture  can  be 
made  positive. 


620 


A  TEXT-BOOK   ON   SURGERY. 


For  this  purpose  the  bulbous  bougie  is  invaluiible.    These  instruiiiciits 

are  of  two  kinds — the  elastic  or  gum  bougie  of  Dick  (Fig.  618),  and  the 

oval-tipped  wire  bougie  of  Otis  (Fig.  610).     They  should  be  made  of  all 

sizes,  commencing  witli  No.  6  and  ending  witli  Nos.  21  or  2'.i 

(U.  S.  scale).     For  practical  purposes  every  alternate  size,  from 

Nos.  6  to  23  inclusive,  will  suffice.     The  gum  bougie  is  a  safer 


Fia.  618. 

Dick's 

gum 

boiiixie, 

with 
oval  tip. 


Fig.  619. — Otis'.s  oval-tipped  wire  boujjie,  for  locating  strictures  of  the  urLtlini. 

instrument  than  that  composed  of  metal,  since  it  is  incapable  of 
doing  harm  under  any  circumstances.  It  is  objectionable,  how- 
ever, on  account  of  its  liability  to  be  spoiled  by  heat,  and  of 
becoming  fragile  from  age.  It  should  always  he  slowly  warmed 
to  about  the  temperature  of  the  body  before  being  introduced. 
The  wire  bougies  are  thoroughly  satisfactory  instruments,  and 
incai)al)le  of  injury  to  the  urethra  if  ordinary  care  is  taken. 
The  bulbs  are  oval,  the  wire  is  ilexible,  and  is  screwed  into  the 
bulb  for  security.  The  sizes  are  the  same  as  for  the  gum  bougies 
just  given. 


^^s^^ 


Fio.  620. — Longitudinal  section  of  the  urethra,  showing  the  ilianieter  of  tlie  canal  at  various 
points.     «,  Prostatic  ;   A,  membranous;   c,  penile  portion.     (After  Thompson.) 

In  the  effort  to  locate  a  stricture,  the  different  diameters  of  the 
normal  urethra  at  various  points  in  this  canal  must  be  borne  in 
mind.  The  meatus  is  least  dilatable,  and  the  membranous  por- 
tion next  in  order.  Immediately  behind  the  meatus  there  is  an 
expansion  into  the  fos.sa  navicularis,  and  from  this  point  to  the 
suspensory  ligament  (the  junction  of  the  penile  and  perineal 
urethra),  the  diameter  is  about  the  same.  From  the  suspensory 
ligament  to  the  anterior  layer  of  the  triangidar  ligament,  the 
diameter  gradually  increases.     This,  the  bulbous  portion,  is  the 

largest  part  of  the  canal.     Behind  the  memln'anous  portion  there  is  a 

second  expansion  in  the  prostate  (Fig.  620). 

The  patient  should  be  placed  upon  the  table  or  bed  in  the  dorsa'. 

decubitus.    In  order  to  secure  insensibility,  from  twenty  to  thirty  minims 

of  a  4-per-cent  solution  of  cocaine  should  be  thrown  into  the  urethra. 


THE  URETHRA— STRICTURE.  621 

This  may  be  done  with  the  ordinary  hypodei-mic  syringe,  to  which  Otis's 
cocaine-tube  (Fig.  621)  is  attached.  It  is  not  necessary  to  carry  the  point 
more  than  one  inch  beyond  the  meatus,  when  the  syringe  is  emptied  and 
the  patient  directed  to  grasp  tlie  glans  and  retain  the  injection  after  the 
tube  is  removed.  In  live  minutes  local  anajsthesia  is  obtained.  A  bulb  of 
medium  size  is  selected  and  properly  warmed  and  oiled.  The  wire  is  not 
curved  in  exploration  of  the  urethra  anterior  to  the  membranous  portion. 
The  penis  should  be  held  at  about  a  right  angle  to  the  plane  of  the  body, 
and,  as  the  instrument  is  being  introduced,  the  organ  should  be  elon- 
gated in  order  to  obliterate  any  folds  in  the  mucous  menil)rane.  This 
membrane  is  not  so  closely  attached  to  the  connective  tissue  of  the  cor- 
pus spongiosum  but  tliat  it  can  l)e  iiercei)tibly  displaced  up  and  down 
and  doubled  upon  itself  if  sutiicient  force  is  ajtplied.  If  no  stiicture  of 
caliber  smaller  than  the  bulb  is  encountered,  it  will  glide  smoothly  and 
uninterruptedly  down  to  a  point  about  five  inches  from  the  meatus,  where 
it  will  be  arrested,  having  reached  the  end  of  the  bulbous  i)ortion  and 


Tig.  621. — Otis's  cocaine-tube  for  tlie  urethra. 


lodged  in  a  pocket  just  in  front  of  the  anterior  layer  of  the  triangular 
ligament.  Withdrawing  the  instrument,  it  will  in  all  probability  return 
as  smoothly  as  it  entered.  If,  however,  a  stricture  exists,  and  the  bulb 
used  is  about  the  size  of  the  lumen  of  the  stricture,  as  it  is  carried  into 
the  nretlira  a  slight  resistance  will  be  felt.  As  the  instrument  is  with- 
drawn, the  broad  shoulder  of  the  oval  v.ill  come  in  contact  with  the  ob- 
struction, where  it  will  be  arrested.  The  penis  should  now  be  allowed 
to  retract,  and  the  thumb  and  finger  of  the  left  hand  sliii])ed  down  to 
the  level  of  the  meatus,  where  the  wire  is  grasped  and  slightly  bent. 
The  instrument  is  steadily  drawn  through  the  stricture,  and,  as  soon  as 
the  resistance  ceases,  the  wire  is  again  bent  at  the  level  of  the  meatus. 
The  distance  between  the  two  points  at  which  the  wire  is  bent  represents 
the  extent  of  the  stricture. 

When  it  becomes  necessary  to  search  the  urethra  beyond  the  bulb- 
ous portion,  the  wire  should  be  bent  to  correspond  to  the  normal 
curve  of  the  deep  urethra.  The  handle  of  the  instrument  should  be 
bent  in  an  opposite  direction  in  order  to  prevent  the  possibility  of 
getting  the  point  of  the  bougie  turned  toward  the  perinjeum.  It  is 
introduced  in  the  same  way  as  the  catheter  or  steel  sound.  When  the 
triangular  ligament  and  compressor-iirethrfe  muscle  are  encountered, 
by  depressing  the  handle  toward  the  thighs  of  the  patient,  the  bulb  is 
made  to  rise  out  of  the  pocket  in  front  of  the  anterior  layer  of  the  liga- 
ment and  to  pass  into  the  membranous  portion.  If  a  stricture  is  present 
the  resistanc(>,  if  not  felt  as  the  bulb  goes  through,  will  certainly  be 
appreciated  as  it  is  withdrawn,  if  the  instrument  is  large  enough.     If 


622  A  TEXT-BOOK   ON   SURGERY. 

the  patient  is  not  narcotized,  spasmodic  contraction  of  the  compressor 
muscle  may  arrest  the  bulb,  and,  in  a  certain  sense,  simulate  stricture. 

In  the  resistance  of  tlif  muscle  there  is  a  roundness,  smoothness,  and 
elasticity  which  differs  froMi  the  rouyli  surface  of  cicatricial  tissue  and 
the  inelastic  grip  of  a  stricture.  When  the  obstruction  is  felt,  tlie  same 
method  of  measurement  and  location  is  to  be  observed.  A  stricture  may 
be  roughly  estimated  by  the  iutroductiou  of  a  catheter,  ordinary  bougie, 
or  steel  sound,  but  it  can  not  be  intelligently  or  satisfactorily  defined 
without  the  oval  bulbs. 

Not  infrequently  it  will  be  found  that  the  meatus  is  too  narnnv  to 
admit  a  bulb  of  sufficient  size  to  define  the  stricture,  necessitating  divis- 
ion of  the  meatus  {meatomy).  This  operation  nuiy  be  done  with  an 
ordinary  scalpel  or  bistoury,  but  with  nothing  like  the  exactness  and 
freedom  fi-om  pain  which  is  secured  when  the  urethrotome  is  employed. 
The  incision  should  be  made  in  the  median  line,  and  should  correspond 
to  the  Hoor  of  the  urethra.  It  sliould  not  extend  deep  enough  to  wound 
the  artery  of  the  fr?enum,  nor  should  it  be  any  deeper  than  is  sufhcient 
to  admit  the  larger  bougies. 

If  the  bistoury  is  employed,  the  operator  grasps  the  glans  between 
the  thumb  and  finger  of  tlie  left  hand,  introduces  the  knife,  cutting-edge 
downward,  a  distance  of  a  half-inch,  and  cuts  carefully  outward.  Tlie 
injection  of  cocaine  solution  into  the  tissues  of  the  part  incised  will 
render  the  operation  i^erfectly  painless.  The  iirethrotome  of  Dr.  E.  A. 
Banks,  in  addition  to  its  usefulness  in  dividing  deeper  strictures,  is 
especially  serviceable  in  performing  meatomy.  It  consists  of  a  handle, 
shaft,  and  a  series  of  bulbs.  The  shaft  is  graduated  and  hollow,  and 
has  extending  through  it  a  rod  connecting  with  the  blade.  The  bulbs 
are  of  various  sizes,  are  fenestrated,  and  are  screwed  on  to  the  tip  in  such 
a  way  that  the  window  falls  directly  over  the  blade  which  is  to  be  pro- 
jected through  it.  Upon  the  handle  is  a  sliding-knob  for  sheathing  or 
projecting  the  knife,  and,  at  the  end,  a  screw-gauge  which  sets  the  blade 
for  cutting  to  any  desired  depth  (Fig.  622). 

I 


Fig.  622.— Dr.  E.  A.  B.ink»'6  urethrotome,    a,  Screw-gauge.     A,  Slidjng-knob.     c,  Bulb.     (/,  Knife. 


The  operation  is  performed  as  follows :  A  bulb  is  selected  which  will 
fit  the  meatus  fairly  tight,  and  screwed  on  to  the  shaft.  The  gauge 
should  next  be  set  to  allow  the  knife  to  cut  one  eighth  of  an  inch  in 
depth.  The  blade  is  now  concealed,  the  bulb  oiled  and  introduced  until 
the  knife,  j)ointuig  directly  to  the  middle  line  of  the  floor,  is  half  an  inch 
from  the  meatus.  While  the  glans  is  held  tightly  between  the  thumb 
and  finger  of  the  left  hand,  the  blade  is  projected  as  far  as  the  gauge 
will  allow,  and  the  instrument  quickly  pulled  out  of  the  urethra.  Even 
when  cocaine  is  not  employed,  this  incision  gives  scarcely  any  pain. 
The  bulbous  bougie  should  now  lie  introduced,  and,  if  the  meatus  is  still 
too  narrow,  the  incision  should  be  made  deeper.     In  order  to  prevent  a 


THE  URETHRA— STRICTFRE.  623 

recontraction  of  the  opening,  it  is  necessary  to  dilate  the  meatus  at  in- 
tervals of  from  two  to  four  clays  for  five  or  six  weeks  after  the  operation. 

In  strictures  of  very  small  caliber,  and  in  long  and  tortuous  strictures, 
the  oval  bulbs  can  not  be  used.  The  extent  of  such  strictures  can  not 
be  made  out  with  accuracy  until,  by  the  use  of  filiform  bougies  and  care- 
ful dilatation,  the  smaller  searchers  can  be  introduced. 

In  certain  rare  cases  of  lateral  stricture,  the  exact  location  of  that 
portion  of  the  urethral  circumference  involved  in  the  contraction  may 
be  determined  by  employing  the  indicator  (Fig.  623),  which  is  practically 


Vg/*  d.  BEYNDtBS  -CQ 

Fig.  G23. — Indicator  tor  locitiu;^  lateral  striclures  of  the  urethra. 

a  section  of  half  of  an  ordinary  bulb.  If  this  instrument  is  introduced 
with  the  smooth  surface  directed  toward  the  projecting  band,  it  will 
pass  in  and  out  with  equal  facility.  If,  however,  it  is  turned  with  the 
opposite  side  toward  the  stricture,  it  will  be  perceptibly  arrested  as  it  is 
withdi'awn.  The  knob  on  the  handle  which  corresponds  to  the  shoulder 
of  the  bulb  will  indicate  the  part  of  the  urethral  wall  in  which  the  strict- 
ure is  situated. 

Treatment. — The  treatment  of  organic  stricture  of  the  urethra  may 
be  hj  division,  or  dilatation.  In  the  former  operation  the  stricture  is 
incised  from  within  {internal  urethrotomy),  or  from  without  {external 
urethrotomy).  In  the  latter,  the  stricture  is  gradually  dilated  by  the 
introduction  of  bougies  or  sounds.  Dilatation  may  be  confinuons  or 
interrHjjted.  Immediate  dilatation,  or  diimlsion  of  a  stricture,  as  com- 
pared to  urethrotomy,  is  an  unscientific  and  unsafe  procedure,  and  is 
rarely,  if  ever.  Justifiable.  With  the  urethrotome,  the  contraction  is  di- 
vided with  accuracy  and  jirecision  ;  with  the  divulsor,  the  force  is  blindly 
applied,  and  the  depth  and  direction  of  the  tear  is  not  safely  within  the 
control  of  the  operator. 

It  is  difficult  to  lay  down  any  rule  for  the  selection  of  the  method  of 
treatment  to  be  followed  in  any  given  stricture.  In  general  it  may  be 
said  that  internal  tirethrotomy  is  preferable  in  all  strictures  antei-ior  to 
the  membranous  portion,  and  some  form  of  dilatation  in  tho.se  sitviated 
in  this  portion,  or  in  the  rare  cases  behind  it.  The  exceptions  to  this 
rule  will  be  presently  considered. 

The  method  of  interrupted  dilatation  by  the  frequent  introduction  of 
sounds  or  bougies  may  be  successfully  applied  to  narrow  annular  strict- 
ures of  comparatively  recent  date,  but  division  of  the  stricture  and  sub- 
sequent dilatation  not  only  offers  the  quickest  and  surest  means  of  relief, 
but  is  much  less  j)ainful  than  dilatation  without  incision.  The  employ- 
ment of  cocaine  in  urethral  surgery  has  removed  two  great  obstacles  to 
the  cutting  operation,  namely — the  patient's  dread  of  pain  on  the  one 
hand,  and  that  of  ether  narcosis  on  the  other. 

Many  strictures  are,  however,  of  such  small  caliber  that  a  urethro- 
tome can  not  be  introduced,  and  it  becomes  necessary  to  dilate  them  u]i 
to  a  size  sufficient  to  admit  the  urethrotome,  or  to  divide  the  stricture  by 


624  A  TEXT-BOOK   ON   SURGERY. 

cuttin<i;  down  n\Mm  it  through  the  integument,  an  operation  known  as 
external  urdh  rotomy. 

Internal  Urdhrotomy. — In  performing  this  operation  a  sufficient  de- 
gree of  anaesthesia  can  be  obtained  by  the  use  of  cocaine  in  the  vast  ma- 
jority of  cases.  "When  the  stricture  is  of  small  caliber,  requiring  a  deep 
incision  from  one  to  two  or  nioi-e  inches  in  length,  ether  narcosis  is  ad- 
visable. 

Operation. — Having  injected  Zss.  of  4-per-cent  cocaine  into  the  ure- 
thra, the  stricture  should  be  accurately  located,  and  its  diameter  and 
extent  tletermined  l)y  the  bulbous  wire  bougies,  as  just  descrilxnl.  If  it 
is  of  small  caliber,  thus  necessitating  a  deep  incision,  a  greater  degree 
of  insensibility  may  lie  required  than  can  be  obtained  by  cocaine  apjilied 
to  the  mucous  membrane  of  tlie  urethra.  This  is  readily  obtained  by 
carrying  a  delicate  hypodermic  needle  into  the  tissues  in  the  line  of  in- 
cision, and  injecting  from  twenty  to  thirty  minims  of  a  4-per-cent  soluti(  >n. 
The  distance  from  the  meatus  to  the  posterior  boundary  of  the  sti-ict- 
ure  is  then  measured  on  the  urethrotome,  beginning  at  the  point  where 
the  knife  is  projected,  and  extending  toward  the  handle.  One  fourth 
of  an  inch  should  be  added  to  this  distance  in  order  to  make  it  certain 
that  the  knife  is  carried  well  behind  the  posterior  limit  of  the  contrac- 
tion. This  point  on  the  instrument  is  indicated  by  a  small  ring  clipped 
from  the  end  of  a  rubber  tube  and  slipped  over  the  shaft.  It  is  now 
ready  for  introduction. 

In  the  selection  of  a  urethrotome,  the  instrument  of  Otis  will  be  found 
to  fill  all  the  indications  more  satisfactorily  than  any  other  (Fig.  G24).    It 


Fio.  624. — Otis's  dilating  urethrotome,  ^'ith  tlie  author's  cog-'wheel  attachment. 

consists  of  a  shaft,  handle,  and  blades.  The  shaft  is  composed  of  two 
bars,  which  can  be  separated  or  closed  by  turning  a  screw  at  the  handle, 
where  there  is  arranged  a  dial  which  registers  the  exact  degree  of  dila- 
tation effected  by  the  separation  of  the  bars.  In  the  upper  bar  of  the 
shaft  is  a  slot  or  groove,  along  which  the  knife  is  carried.  When  it 
arrives  near  the  point  of  the  shaft,  the  blade  sinks  into  a  depression 
and  disappears. 

I  have  added  to  this  instrunu^nt  a  cog-wheel  apparatus,  attached  near 
the  handle,  by  the  use  of  which  the  knife  is  carried  steadily  forward  or 
backward,  and  is  made  to  cut  with  mathematical  precision. 

The  operator  should  stand  to  the  right  side  of  the  patient,  who  is 
resting  on  the  back,  with  the  legs  fully  extended.  The  knife  should  be 
can-ied  forward  until  it  disappears  near  the  tip  of  the  urethrotome,  the 
bars  of  which  are  now  closed  and  oiled  as  far  as  it  is  to  be  introduced. 
The  glans  penis  is  grasped  between  the  thumb  and  finger  of  the  left 
hand,  the  organ  held  in  the  same  position  as  when  the  stricture  was 


THE  URETHRA— STRICTURE.  625 

located,  and  the  instrument  carried  in  until  the  rubber  ring  touches  the 
meatus.  The  left  hand,  releasing  the  penis,  is  made  to  grasp  the  handle 
of  the  urethrotome  and  steady  it,  while  with  the  right  the  dilating-screw 
is  turned  until  the  arrow  on  the  dial  indicates  a  separation  of  the  bars 
equal  to  the  diameter  of  the  bulb  which  located  the  stricture.  By  turn- 
ing the  cog-wheel  the  knife  is  now  made  to  travel  through  the  moi'e  su- 
perficial jjortions  of  the  stricture  from  beliind  forward  and  along  the 
median  line  of  the  roof  of  the  urethra.  The  incision  should  commence 
a  quarter  of  an  inch  behind  the  stricture,  and  should  temiinate  the 
same  distance  in  front  of  the  anterior  boundary.  Without  changing 
the  position  of  the  urethrotome,  the  knife  is  rapidly  run  back  to  its 
original  position,  the  dilatation  increased  one  size  more,  and  the  knife 
again  carried  more  deeply  through  the  track  of  the  first  incision.  This 
manoeuvre  is  repeated  until  the  stricture  is  divided  up  to  Nos.  21  to  23 
(U.  S.).  The  instrument  is  now  withdrawn  after  the  knife  is  concealed 
and  the  blades  half-closed.  If  the  bars  are  brought  closely  together, 
the  mucous  membrane  may  be  caught  between  them.  In  order  to  dem- 
onstrate a  perfect  division  of  all  the  bands,  the  larger  bulbs  should  be 
introduced,  and,  if  these  catch  at  any  point,  a  further  incision  is  required. 
Or  a  full-sized  sound  (Nos.  21  to  23)  may  be  carried  through  the  strict- 
ure, and  any  undivided  fibers  torn  or  stretched. 

Haemorrhage  after  internal  urethrotomy  is  usually  slight.  "NVlien  the 
incision  has  been  made  in  the  pendulous  i:»art  of  the  urethra,  it  may  be 
readily  arrested  by  turning  the  penis  up  on  the  belly,  laying  a  handful 
of  cotton  or  gauze  over  the  organ,  and  strapping  it  down  with  a  band- 
age carried  around  the  pelvis.  Behind  this  portion,  a  compress  along 
the  peringeum,  or  a  large  gum  bougie  in  the  canal,  will  control  the  bleed- 
ing. The  patient  should  be  put  to  bed  at  once,  and  requii-ed  to  remain 
quiet  for  several  days. 

Not  infrequently  within  twenty-four  hours  after  urethrotomy,  or  the 
introduction  of  a  sound  or  other  instrument  into  the  uretlira,  the  patient 
is  seized  with  rigors  or  a  pronounced  chill,  followed  by  a  variable  rise  in 
temperattire,  or  the  fever  may  occur  without  any  premonitory  chill. 
When  the  thermometer  registers  100°  F.,  it  is  a  wnse  precaution  to  ad- 
minister antipyrin  in  doses  of  from  grs.  x-xx,  and  repeat  this  every 
hour  until  the  decline  in  temperature  is  below  100°.  If  the  pulse  is  cor- 
respondingly increased,  tincture  of  aconite-root  should  be  given  at  the 
same  time. 

The  repeated  introduction  of  steel  sounds  or  gum  bougies  is  essen- 
tial to  the  successful  after-treatment  of  internal  urethrotomy.  If  there 
is  no  marked  febrile  movement,  the  dilatation  should  be  commenced  on 
the  second  or  third  day  after  the  operation.  If  fever  exists,  the  use  of 
the  sounds  should  be  })ostponed.  Cocaine  should  be  employed,  for,  as 
a  rule,  the  introduction  of  the  sound  is  more  painful  tlian  the  incision. 
The  urethra  should  be  stretched  to  the  full  size  of  the  sound  introduced 
after  the  cutting.  It  is  well  to  begin  with  No.  17,  and  follow  this  with 
Nos.  19,  20,  and  21,  or  higher,  if  the  uretlira  is  unusually  capaciotis. 

Tliis  should  be  repeated  every  second  or  third  day  for  a  period  of  about 
40 


626  A  TEXT-BOOK   ON   SURGERY. 

three  weeks,  every  fourtH  f)r  fifth  day  for  the  same  period  of  time,  then 
once  a  week  for  three  weeks,  and  twice  a  month  for  three  or  fonr  months. 
It  is  essential  to  keep  tlie  walls  of  the  incision  apart  until  they  are  lined 
with  new-formed  epithelia. 

If  cystitis,  epididymitis,  or  t>rchitis  ensue  after  urethrotomy,  all 
operative  measures  should  be  discontinued  until  these  symptoms  disap- 
pear. • 

The  prognosis  after  urethrotomy  should  be  guarded.  ISfany  cases 
do  not  recur,  but  a  stricture  of  long  standing,  with  extensive  induration, 
no  matter  how  thoroughly  divided  and  carefully  treated,  tends  to  recur. 
It  til  us  becomes  neces.sary  to  employ  dilatation,  either  with  a  sound  in 
the  hands  of  the  surgeon,  or  a  soft  bougie  if  this  duty  is  intrusted  to 
the  patient,  at  intervals  of  every  two  or  three  months,  and  in  some  in- 
stances oftener,  during  the  life  of  the  individual.  That  the  milder  forms 
of  annular  stricture  may  be  permanently  cured  by  judicious  treatment 
is  satisfactorily  established. 

In  a  certain  proportion  of  cases  the  stricture  will  be  found  so  close  or 
tigl)t  that  the  urethrotome  can  not  be  passed  through  it,  and  before  the 
division  can  be  effected  it  is  necessary  to  dilate  the  constriction  until 
this  instrument  can  be  introduced.  In  accomplishing  this  purpose  two 
excellent  methods  are  at  the  disposal  of  the  surgeon,  by  either  of  which, 
if  patiently  and  skillfully  utilized,  the  necessity  of  external  urethrotomy 
may  be  obviated  in  all  but  a  very  limited  class  of  cases.  The  methods 
are,  in  order  of  excellence,  (1)  immediate  dilatation  with  Banks's  dilating 
filiform  bougies,  and  (2)  continuous  dilatation  by  inserting  and  leaving 
iu  the  urethra  one  or  more  whalebone  filiforms,  or  a  larger  gum  bougie. 
Of  the  procedures  of  Dr.  E.  A.  Banks  and  Sir  Henry  Thompson,  the 
former  is  by  far  the  most  satisfactory.  Its  adoption  has  left  only  a  small 
proportion  of  strictures  for  continuous  dilatation. 

The  dilating  filiform  bougie  (Fig.  625)  is  thus  employed :  The  urethra 
is  elongated  by  pulling  upon  the  glans,  and  a  small  syringef  ul  of  sweet- 


EC 


^^  TJTir.yy 


Flo.  625. — Banks's  dilating  filiform  bouses. 

oil  is  thrown  into  the  canal.  The  filiform  is  introduced,  and,  when  any 
resistance  is  encountered,  it  is  slightly  withdrawn  and  again  pushed  in. 
By  this  manoeuvre  the  small  tip  of  the  instrument  may  be  insinuated 
through  even  a  long  and  tortuous  tight  stricture.  Once  engaged  in  the 
opening,  it  should  be  carefully  pushed  down  until  it  is  felt  in  the  gi-asp 
of  the  constriction,  and  then  forced  steadily  through  until  the  full  dilat- 
ing capacity  of  the  largest  part  of  the  bougie  has  traveled  through  the 
stricture.  A  larger  size  should  ))e  at  once  introduced,  or  the  urethro- 
tome may  be  carried  through  the  opening. 


THE  URETHRA— STRICTURE.  627 

This  bougie  may  be  employed  with  perfect  safety.  When  fully  in- 
troduced, the  filiform  j)ortion  passes  into  the  bladder,  and,  if  this  organ 
is  empty,  it  curls  upon  itself  from  the  resistance  of  the  vesical  wall.  It 
is  especially  adapted  to  close  strictures  of  the  deep  perineal  and  mem- 
bi-anous  urethra. 

If,  after  careful  trial,  it  is  impossible  to  get  the  filiform  into  the 
opening,  the  patient  should  be  jjut  to  bed  and  given  the  benefit  of  a 
full  dose  of  quinia  and  morphia.  If  the  urine  can  not  be  passed,  supra- 
pubic aspiration  is  indicated.  After  fi'om  twelve  t-o  twenty-four  hours 
it  will  usually  be  discovered  that  the  filiform  will  slip  readily  into  the 
bladder.  As  soon  as  the  dilatation  is  sufficient  to  admit  the  urethrotome, 
the  operation  of  internal  urethrotomy  should  be  performed. 


zGi^= 


/Olf=>= 


CB=>— 


Fig.  626. — Gum  filiform  bonnes. 


In  contimtous  dilatation,  the  filiform  bougie  (Figs.  626,  627),  or  a 
small  gum  bougie,  is  insinuated  through  the  stricture  and  tied  in  position 
in  the  urethra  by  fixing  a  narrow  strip  of  adhesive  plaster  around  the 
prepuce  behind  the  corona  glandis, 
and  attaching  from  this  to  the  end 
of    the    bougie    three    or  four  silk 
threads  (Fig.  628). 


\ 


Fio.  627. — Wlialebone  filifonn  bougies.  Fio.  62.S.— Bougie  tied  in  lor  continuous  dilatatioa. 

The  walls  of  the  stricture  break  down  under  the  constant  pressure  of 
the  whalebone  or  elastic  instrument,  and  it  will  be  found  that  a  bougie, 
with  difficulty  introduced  and  tightly  held  by  the  stricture  soon  after  it 
is  carried  through,  will,  within  twenty-four  hours,  become  loose  and 
easily  movable,  and  a  larger  instrument  will  readily  pass  into  the  same 
opening.  As  soon  as  the  dilatation  has  proceeded  to  the  required  ex- 
tent, the  urethrotome  should  be  employed  and  a  division  effected. 

Strictures  of  the  Membranous  Urethra. — Strictures  of  the  deep  ure- 
thra are  amenable  to  treatment  by  modi  fled  internal  urethrotomy  av-iX  by 
external  urethrotomy  or  perineal  section. 

The  former  method  consists  in  the  rapid  dilatation  of  the  stricture 
with  the  dilating  filiform  bougie  until  the  Otis  urethrotome  can  be  intro- 
duced. Tlie  straight  instrument  shown  in  Fig.  624  can  be  readily  em- 
ployed in  this  portion  of  the  urethra.  It  is  carried  into  the  stricture 
until  the  knife  is  at  its  posterior  limit,  when,  without  separating  the 
bars  of  the  urethrotome — that  is,  without  dilatation — the  blade  is  care- 


628  A  TEXT-BOOK   ON   SURGERY. 

fully  drawn  along  the  roof  of  the  nrethra,  making  a  shallow  incision  in 
the  wall  of  the  stricture.  It  should  now  be  concealed,  and  the  dilating 
power  of  the  urethrorome  employed.  Tiiese  shallow  incisions  maybe 
made  on  the  lateral  aspects  of  the  canal  as  well  as  along  its  roof.  By 
this  operation  the  stricture  is  nicked  and  then  dilated.  If  the  incision 
were  made  when  the  bars  of  the  urethrotome  had  i)iit  the  stricture  on 
the  stretch,  the  large  vessels  of  this  part  of  the  urethra  would  be  en- 
dangered. The  steel  sounds  should  be  used  as  advised  after  internal 
urethrotomy  in  the  anterior  portion  of  the  canal. 

External  lirethrotomy,  or  perineal  section,  is  an  operation  for  the 
relief  of  clo.se  organic  stricture  of  the  bulbous  or  membranous  portions 
of  the  urethra  which  can  not  be  reached  through  the  urethra.  With  the 
exception  of  those  cases  where  urinary  fistula  or  chronic  abscess  exists 
as  a  result  of  stricture,  the  conditions  which  justify  this  operation  are 
extremely  rare. 

It  is  performed  with  or  without  a  guide.  When  a  sound  or  bougie 
can  be  carried  through  the  obstruction  into  the  bladder,  the  procedure 
is  much  simplified.  ^Vithout  this  guide  the  operation  is  surrounded 
with  considera])le  difhcalty.  In  external  urethrotomy,  the  patient  is 
placed  in  the  lithotomy  position,  being  prepared  as  for  this  operation. 
After  the  anaesthesia  is  complete,  a  careful  and  final  effort  should  be 
made  to  carry  a  filiform  or  soft  bougie  through  the  strictuic  and  into 
the  bladder.  If  this  can  not  be  done,  a  good-sized  sound  shduld  be  car- 
ried down  to  the  obstruction,  and  this  will  serve  to  guide  the  operator 
to  the  commencement  of  the  stricture. 

An  incision  is  then  made  exactly  in  the  median  line,  the  anterior  limit 
being  slightly  in  front  of  the  ascertained  commencement  of  the  stricture, 
the  posterior  extending  towaid  the  anus  a  sufficient  distance.  In  making 
this  incision  the  scrotum  should  be  held  up  by  an  assistant,  who  is  di- 
rected not  to  disijlace  the  median  raphe  to  either  side.  The  legs  must 
also  be  held  in  the  same  relative  position. 

The  bleeding  is  usually  considerable,  as  the  vascular  tissue  of  the 
bulb  is  divided.  All  vessels  should  be  secured ;  but  the  oozing,  which 
is  general,  need  not  retard  the  operation.  As  soon  as  the  sound  or  fili- 
form, at  the  anterior  margin  of  the  constriction,  is  seen,  the  division 
should  continue  along  the  guide  until  the  healthy  urethra  is  reached  be- 
yond the  stricture.  If  no  guide  has  been  introduced,  the  dissection 
should  be  carried  back  in  the  known  direction  of  the  base  of  the  blad- 
der, guided  by  the  location  of  the  prostate  with  the  finger  introduced 
into  the  rectum.  The  first  indication  that  the  canal  is  reached  behind 
the  stricture  will  be  a  gush  of  urine.  On  account  of  the  obstruction, 
the  urethra  between  it  and  the  bladder  is  widely  dilated,  and  for  this 
reason  is  more  readily  found. 

It  is  essential  to  the  success  of  this  operation  that  all  cicatricial  tissue 
be  dissected  out.  A  large-sized  steel  sound  should  now  be  introduced 
through  the  meatus  and  into  the  bladder.  If  any  difficulty  is  met  with 
in  introducing  this  instrument,  a  flexil>le  bougie  may  be  substituted. 
It  is  not  advisable  to  leave  the  instrument  in  the  urethi-a.     If  the  bleed- 


THE  URETHRA— STRICTURE. 


629 


ing  has  not  ceased,  the- wound  should  be  packed  temporarily  with  sub- 
limate gauze,  held  in  position  by  a  T-bandage.  When  there  is  no  haem- 
orrhage, a  loose  dressing  should  be  applied. 

The  urine  usually  escapes  through  the  \vt)und  for  the  first  few  days, 
and  afterward  partly  through  the  wound  and  urethra.  In  rare  instances 
it  escapes  uninterruptedly  through  the  urethra.  The  after-treatment 
consists  in  the  introduction  of  the  sounds  or  bougies  (as  above  directed) 
through  the  urethra  as  far  as  the  neck  of  the  bladder.  This  opera- 
tion should  be  repeated  every  three  or  four  days  until  the  urine  ceases 
to  escape  through  the  wound,  and  once  a  week  thereafter  for  several 
months. 

Interrupted  Dilatation. — In  the  treatment  of  stricture  of  the  urethra 
by  this  method,  there  are  required  steel  sounds  axi(\  flexible  bovgies. 
Steel  sounds  are  of  two  patterns,  the  straight  and  curved.  The  former 
are  preferable  for  dilating  strictures  anterior  to  the  membranous  portion, 
whUe  beyond  this  point  the  curved  instruments  are  necessary.  The  most 
satisfactory  instruments  are  those  constructed  upon  the  United  States 
scale,*  which  commences  with  the  smallest  steel  instrument,  -^^  of  an 


Fifi.  629. 

inch  iu  diameter,  and  increases  -^-^  of  an  inch  in  diameter  for  each  suc- 
cessive sound  to  No.  25  inclusive,  equal  to  ||^  of  an  inch.  Nos.  1  to  8, 
inclusive,  are  filiform  and  elastic  bougies. 

A  straight  sound  should  be  six  inches  in  length  clear  of  (he  handle, 
slightly  ccmical  from  the  tip,  back  for  a  distance  of  one  and  a  half  inch. 
This  conicity  should  increase  one  size  for  every  half-inch  for  this  distance. 
Thus,  a  sound  which  measures  No.  17  at  the  tip  increases  to  No.  18  one 
half  inch  back,  to  No.  19  at  one  inch,  and  is  No.  20  at  one  and  a  half 
inch  from  the  point,  and  continues  this  size  for  the  entire  shaft. 

A  curred  sound  should  be  nine  inches  long  clear  of  the  handle.  The 
curve  should  involve  only  the  last  two  inches.  The  conicity  extends 
also  one  and  a  half  inch  from  the  tip,  increasing  one  size  for  every  half- 
inch  until  the  full  size  is  reached  at  one  and  a  half  inch  from  the  point. 

*  The  unit  of  the  French  scale  is  one  third  of  a  millimetre  (about  J^  oi  an  inch),  and  each 
size  up  to  No.  30,  inclusive,  increases  one  third  of  a  millimetre  in  diauitter.  Divide  any  given 
number  of  this  scale  by  three,  subtract  the  quotient,  and  the  remainder  aiipro.ximatcs  the  oor- 
respondintr  size  on  the  above  scale.  Thus,  No.  3(1,  French,  divided  bv  :j  =  10;  30  —  10  =  20; 
or.  No.  30,  Fi-ench  =  No.  20,  U.'S. 


630 


A  TEXT-BOOK   OX   SURGERY. 


Thus,  an  instrument  the  shaft  of  which  measures  No.  2(>,  is  17  at  the  tip, 
18  at  one  half  inch,  and  19  at  one  inch  farther  back. 


Fig.  630. — Curved  and  straight  conical  sounds. 

The  cune  should  be  made  to  correspond  to  that  of  the  normal  deep 
urethra,  which  is  that  of  a  circle  with  a  diameter  of  three  and  a  quarter 
inches;  "and  the  proper  length  of  arc  of  such  a  circle  to  represent  the 
8ub-i)ubic  curve  is  that  subtended  by  a  chord  two  and  three  quarters 
inches  long""  *  (Fig.  631). 


Fio.  631. 


Flexible  bougies  are  of  various  sizes,  being  conical  for  two  or  three 
inches,  and  olive-pointed  (Figs.  632-635).  They  are  exceedingly  use- 
ful instruments,  and,  when  warmed  before  introduction,  are  incapable 
of  injury  to  the  urethra,  even  when  an  unusual  degree  of  force  is  em- 


*  VaD  Baren. 


THE   URETHRA— FOREIGN   BODIES. 


681 


Fjg.  632. 


Fio.  633. 


Fig.  634. 


flG 


ployed.     The  black  French  bougie  is  preferable.     The  filiform  instru- 
ment has  already  been  described. 

In  dilating  a  strictxare  with  the  conical  steel  sound,  the  method  of  in- 
troduction is  identical  with  that  given  in  using  the  metal  catheter.  In 
the  interrupted  dilata- 
tion a  mild  degree  of 
force  is  exercised,  and 
the  seance  is  repeated 
on  every  second,  third, 
or  fourth  day.  The 
length  of  the  interval 
between  the  introduc- 
tions must  be  deter- 
mined by  the  symp- 
toms in  each  case,  the 
object  being  to  accom- 
plish moderate  divul- 
sion  at  each  sitting  with- 
out producing  marked  inflammation.  The  sound  should  never  be  carried 
beyond  the  point  where  its  full  dilating  power  is  applied  to  the  strict- 
ure. In  this  way  irritation  of  the  prostatic  urethra  and  neck  of  the 
bladder  may  be  avoided  in  all  save  the  deepest  variety  of  strictures. 

The  dilatation  of  strictures  by  the  use  of  conical  steel  sounds  should 
be  limited  to  those  cases  in  which  the  stricture  is  of  sufficient  caliber 
to  admit  at  least  No.  15,  U.  S.,  and  is  narrow  or  linear  in  character, 
so  that  it  may  be  made  to  give  way  without  the  employment  of  too 
great  force.  The  smaller  sounds  are  capable  of  penetrating  the  walls  of 
the  urethra  unless  they  are  used  with  great  skill  and  carefulness,  Avhile 
the  larger  instruments  will  not,  within  the  limit  of  safety,  succeed  in 
the  dilatation  or  rui)ture  of  a  broad  or  tortuous  stricture.  Incision  with 
the  urethrotome  is  a  safer  and  less  painful  operation,  and  the  sounds 
serve  an  admiralde  purpose  in  the  after-treatment. 

In  using  the  soft  bougies  in  the  anterior  portion  of  the  urethra,  they 
may  be  passed  in  straight ;  but,  when  the  deeper  portion  is  invaded, 
they  should  be  curved  as  much  as  possible^  to  correspond  to  the  sub- 
pubic curve  of  this  canal. 

Foreign  Bodies  in  the  JJretlira. — Calculi  occasionally  lodge  in  tlie 
urethra,  and  substances  introduced  through  the  meatus — as  fragments 
of  a  catheter,  etc. — may  require  removal  by  the  surgeon.  The  diagnosis 
will  be  evident  from  the  symptoms  of  obstruction  to  the  escape  of  urine, 
by  recognition  of  the  body  by  digital  pressure  along  the  canal,  and  by 
exploration  through  the  meatus.  Stone  may  be  made  out  by  the  grating 
sound  which  is  emitted,  or  by  the  sense  of  friction  upon  a  rough  and 
hard  surface  which  is  conveyed  to  the  fingers  along  the  sound.  A  me- 
tallic substance  may  also  be  recognized  by  the  peculiar  click  which  is 
elicited  when  it  is  brought  in  contact  with  the  exploring  instrument. 

Removal  may  be  effected  through  the  meatus,  or  by  incision  directly 
through  rhe  floor  of  the  urethi-a  at  the  point  of  lodgment.     It  is  always 


633 


A  TEXT-BOOK   ON   SURGERY. 


desirable  to  avoid  incision  tliroiigh  the  urethral  wall  when,  by  the  use  of 
forceps  or  any  mechanism,  the  extraction  can  be  effected  by  the  meatus 
without  doing  too  great  violence  to  this  canal.     If  the  substance  is  nar- 


Fio.  636. — Straight  and  curved  alligator-jawed  uretliral  forceps. 

row  and  smooth,  it  may  be  seized  with  the  forceps  (Figs.  G36,  G37)  and  ex- 
tracted. The  straight  alligator-forceps,  or  the  instrument  of  Hale,  is 
preferable  for  the  anterior  portion  of  the  urethra,  while  for  the  deeper 


Fio.  637. — Hale's  iiisti-umoiit  tbr  lemoving  foreign  bodies  from  the  urctlira.     (After  Liiiliart.) 


part  the  curved  instrument  is  more  suitable.     For  a  round  body,  the 
scoop  or  curette  will  prove  more  satisfactory  (Fig.  638). 

In  using  the  forceps,  the  instrument  closed  should  be  carried  down 
until  its  beak  strikes  the  foreign  substance,  when  the  jaws  should  be 
slowly  separated  and  pushed  farther  in,  so  that  they  may  pass  between 
the  lining  membrane  of  the  urethra  and  the  body.  They  should  then 
be  firmly  closed  and  cautiously  moved  a  slight  distance  to  and  fro  in 

oi'der  to  detemiine  whether  the  mu- 
•     cous  membrane  has  been  caught  in 


Fio.  638. — Curette,  or  scoop,  for  the  re- 
moval of  calculus  in  the  urethra. 
(At\er  Van  Buren  and  Kej'cs. ) 


Fig.  639. — Calculi  removed  from 
the  urethra.  (The  author's 
case.) 


the  instrument.  This  danger  will  in  great  part  be  obviated  if,  just  at 
the  moment  when  the  jaws  are  applied  to  the  foreign  substance,  the 
urethra  is  put  upon  the  stretch  by  pulling  upon  and  elongating  the 
penis.  The  canal  should  be  lultricated  by  an  injection  oi  sweet-oil.  If 
stricture  exists,  urethrotomy  may  be  necessary  before  the  substance  can 


CONGENITAL  MALFORMATIONS  OF  THE  URETHRA. 


638 


be  extracted.  In  a  case  which  came  imder  my  care,  two  strictures  were 
divided  with  the  urethrotome.  From  behind  the  first  constriction  two  cal- 
culi were  removed,  and  several  after  the  second  stricture  was  divided  (Fig. 
639).     In  this  oj^eration  a  scoop  proved  more  serviceable  than  the  forceps. 

In  a  second  oi^eration  I  found  it  necessary  to  perform  external  ure- 
tlirott)my,  cutting  directly  down  upf)n  the  calculi  (two  in  nunil)er),  which 
were  easily  removed  through  the  incision.  The  direct  injection  of  cocaine 
into  the  tissues  secured  complete  anaesthesia.  The  wound  should  be  left 
to  close  as  in  the  ordinary  operation  of  perineal  urethrotomy. 

Congenital  Ifalformatioiis  of  the  Urethra. — In  extrophy  of  the  blad- 
der the  urethra  is  absent,  and,  in  certain  rare  anomalies,  it  may  open  into 
the  groin,  upon  the  side  of  the  glans  jjenis,  in  the  median  line  of  the 
dorsum  penis  (epispadias),  in  the  median  line  below  at  any  point  on  the 
corpus  spongiosum  (hypospadias). 

Hypospadias  is  the  most  common  of  the  congenital  deformities  of  the 
urethra.  When  the  opening  is  within  one  inch  of  the  normal  position 
of  the  meatus,  operative  interference  is  not  indicated.  When  the  opening 
is  so  far  back  that  in  S9xual  intercourse  the  semen  can  not  be  ejaculated 
into  the  vagina,  a  plastic  ojieration  may  be  undertaken.  The  chances  of 
failure  are  always  so  great  that  it  is  scarcely  ever  justifiable  to  under- 
take this' operation  in  the  effort  to  establish  an  artificial  channel  for  the 
urine,  for,  even  when  the  opening  is  as  far  back  as  the  perinaeum,  soil- 
ing may  be  prevented  by  urinating  in  the  squatting  posture. 

The  operation  for  the  relief  of  hypospadias  consists  in  introducing 
a  long,  delicate  knife  at  the  apex  of  the  glans,  and  carrying  it  directly 
back  along  the  normal  position  of  the  corpus  spongiosum  until  it  emerges 
in  the  anterior  limit  of  the  urethra  at  the  abnormal  opening.     This  arti- 


Fio.  640.— (After  Liiili;irt.) 


Fig.  642. 


iin.  643. 


ficial  channel  should  be  large  enough  to  admit  a  straight  catheter,  which 
is  now  introduced  through  it  and  well  into  the  urethra  beyond  the  hy- 
pospadias. 

In  closing  the  abnormal  meatus  the  margins  of  the  integument  around 
it  should  be   trimmed  with  delicate  cui'ved  scissors,  parallel   incisions 


634  A  TEXT-BOOK   ON   SURGERY. 

made  on  either  side  of  the  opening  through  the  skin,  the  intervening 
strip  of  integument  carefully  dissected  up  for  sliding,  and  the  edges 
brought  together  by  sutuivs  of  fine  iron-dyed  silk.  The  l<mg  axis  of 
tlie  strips  may  be  parallel  with  the  canal,  or  have  a  horizontal  direction, 
as  may  be  best  suited  to  the  closure  of  the  fistula  (Figs.  640,  641,  642,  643). 
The  sutures  should  be  not  farther  than  one  eighth  of  an  inch  a])art. 
The  catheter  should  be  left  in  position  for  five  or  ten  days,  until  union 
is  complete.  The  sutures  may  be  removed  about  the  seventh  day.  The 
outer  wounds  are  left  to  close  by  granulation.  Interru]ited  dilatatitm 
with  the  straight  steel  sounds  should  be  made  every  three  or  four  days 
for  several  months  after  the  catheter  is  removed. 

JVeojilasms. — Papillomata  and  tibroniata  are  occasionally  met  with 
growing  from  the  mucous  membrane  of  the  urethra.  They  i)roduce 
symptoms  of  obstruction  varying  with  their  shape,  size,  and  point  of 
attachment.  When  situated  near  the  meatus,  they  may  be  ol)served  by 
means  of  the  urethral  speculum  (Fig.  644).     When  deeply  located,  the 


SSs 


Fig.  i5-t4. — I'rethral  speculum  of  H.  Marion-Sims. 

obstruction  may  be  recognized  by  the  bulbous  bougie.  The  only  treat- 
ment is  removal,  which  may  be  done  by  the  wire  snare  or  by  torsion 
with  forceps.  In  extreme  cases,  a  longitudinal  incision  may  be  required 
in  the  median  line  of  the  floor  of  the  penis  in  order  to  effect  removal. 

Cancer  may  originate  in  this  canal,  or  more  frequently  extend  here 
from  malignant  disease  of  the  prepuce  and  glans.  Tuberculosis  also 
occasionally  attacks  the  urethra. 

T^te  Penis. — The  congenital  malformations  of  the  urethra  just  given 
may  be  included  with  defonnities  of  the  jjenis.  The  corpus  spongiosum 
is  at  times  arrested  in  development,  while  the  corpora  cavernosa  are  fully 
formed,  causing  the  organ  to  bow  when  an  erection  occurs.  One  cavern- 
ous body  is,  in  rare  instances,  not  fully  formed,  and,  when  an  erection 
takes  i)lace,  the  curve  is  lateral,  with  the  concavity  toward  the  affected 
side.  The  penis  is  occasionally  double,  with  separate  urethra^.  In  her- 
maphrodites it  is  rudimentary. 

Inflammation  of  this  organ  is  rare,  except  as  a  result  of  traumatism. 
It  occasionally  becomes  involved  by  the  extension  of  a  phlegmonous  or 
erysipelatous  process  from  the  scrotum  or  abdomen,  or  from  urethritis 
and  posthitis.  The  organ  becomes  greatly  swollen,  and  a  painful  con- 
dition of  chordee  is  almost  constant.  Retention  of  urine  may  occur,  as 
well  as  suppuration  or  gangrene. 

In  the  treatment  of  mild  inflammation  of  this  organ,  local  applica- 
tions will  usually  prove  sufficient.  The  tendency  to  erection  shoidd  l)e 
controlled  by  the  use  of  opium  or  chloral  and  potassium  bromide  in  full 


THE  PENIS. 


635 


(loses.  WliPD  gangrene  is  threatened,  free  incisions  in  the  long  axis  of 
the  organ  should  be  practiced. 

Wounds  of  the  penis,  involving  more  than  the  integument,  always 
bleed  profusely.  Hjemorrhage  may  be  controlled  by  direct  compi'essi(jn 
with  a  roller,  or  by  throwing  a  few  turns  of  an  elastic  ligature  around  this 
(jrgan  near  the  pubic  junction.  When  the  urethra  is  divided  in  whole  or 
in  part,  it  is  best  to  stitch  the  separated  walls  together  by  close  sutures 
of  delicate  silk.  Catgut,  though  more  desirable  in  one  sense,  is  too 
readily  absorbed  to  hold  the  edges  of  the  wound  in  contact  for  a  length 
of  time  sufficient  to  secure  union.  It  is  not  usually  necessary  to  insert 
a  catheter,  and  it  is  best  to  dispense  with  this  on  account  of  the  irrita- 
tion it  causes.  Any  tendency  to  stiicture  may  be  ti'eated  later.  When 
the  dense  capsule  of  the  corpus  cavernosum  is  divided,  this  should  be 
included  in  the  sutures  which  are  carried  through  the  wound  in  the  in- 
tegument. A  guarded  prognosis  should  be  made  in  all  deep  injuries  of 
the  penis.  Distortion  during  erecticm,  and  stricture,  are  frequent  results 
of  such  lesions. 

Fracture  of  the  corpora  cavernosa,  an  accident  which  occiirs  in  rare 
instances  as  a  result  of  great  violence  to  the  erected  organ,  is  a  difficult 
injury  to  treat.  Deformity,  with  more  or  less  loss  of  function,  is  apt  to 
ensue.  The  organ  should  be  laid  up  on  the  abdomen,  and  kept  in  a 
condition  of  as  perfect  quiet  as  possible.  Cold  applications  are  indi- 
cated,  and,   in   case   of  _ 


r 


-■'-A, 


i^/ 


J 


■•/ 


strangulation  from  ef- 
fusion of  blood  or  from 
any  other  cause,  free 
longitudinal  incisions 
may  be  necessitated. 

Carcinoma. — Epithe- 
lioma of  the  penis  is  not 
an  uncommon  affection. 
It  commences  as  a  small 
pimple  or  erosion  on 
the  mucous  surface  of 
the  prepuce  or  on  the 
glans,  gradually  spread- 
ing until,  if  left  alone, 
the  entire  organ  is  in- 
volved and  destroyed. 
The  margins  of  the  ulcer 
are  indurated,  elevated, 
sinuous,  and  slightly 
everted.  The  indura- 
tion, as  a  rule,  is  con- 
fined to  the  immediate 
borders  of  the  sore,  not 
extending  into  the  deeper  tissues  unless  inflammation  supervenes.  As 
the  disease  progre.sses,  the  center  of  the  surface  becomes  studded  with 


Fig.  645. 


-Carcinoma  of  the 


{>eni? 
losp 


(From  a  cafe  in  Mount 

ispital.  I 


636  A  TEXT-BOOK   ON   SURGERY. 

buds  of  newly  formed  cells  and  capillaries,  giving  it  an  appearance  not 
unlike  a  cauliflower  (Fig.  64o).  Ulceration  occurs  at  various  portions  of 
the  mass,  and  a  dirty  quality  of  pus  is  exuded.  The  odor  from  the  de- 
comi)osing  tissues  is  X)ecidiarly  jjenetrating  and  offensive. 

Within  a  period  of  time,  varying  from  two  to  six  or  eight  months, 
enlargement  of  the  inguinal  glands  is  observed.  This  enlargement  may 
be  inflammatory  or  metastatic.  As  a  rule,  metastasis  is  not  rapid  in 
epithelioma  of  the  penis,  and  induration  of  the  glands  does  not,  on  this 
account,  i)reclude  the  hope  of  cure  after  amputation. 

The  principal  cause  of  epithelioma  of  the  penis  is  prolonged  irrita- 
tion of  the  glans  and  prepuce  fi-om  retained  secretions.  All  the  cases 
which  have  come  under  my  observation  have  occurred  in  patients  with 
unusually  long  and  tight  prepuces.*  It  is  usually  met  with  in  the  mid- 
dle-aged and  old,  although  it  sometimes  occurs  in  early  adult  life. 

The  diagnosis  of  epithelioma  is  not  very  difficult  after  ulceration 
takes  place.  The  indurated  sinuous  and  everted  borders  of  the  ulcer, 
the  red,  cauliflower-like  appearance  of  the  mass,  and  the  steady  i)rogress 
of  the  disease  in  the  destruction  of  all  the  tissues  in  its  path,  are  symp- 
toms not  met  with  in  any  other  lesion  of  this  organ.  Warty  growths 
(papillomata),  Avhen  not  seen  early  in  their  development,  may  at  times 
simulate  epithelioma,  especially  when  these  vegetations  are  luxuriant, 
are  undergoing  ulceration,  are  covered  with  jiurulent  matter,  and  are 
the  seat  of  repeated  haemorrhages.  No  matter  how  wide-spread  the  paj)- 
illomatous  neoplasm  may  be,  at  the  outskirts  of  the  mass  will  be  found 
tufts  or  minute  warts  sufficiently  isolated  to  be  recognized.  In  the  very 
earliest  stages  of  development  of  the  ulcer  of  epithelioma,  it  is  scarcely 
possible  to  make  a  positive  diagnosis  between  it  and  chancroid,  or  even 
a  simple  ulcer  of  the  prepuce  and  glans  penis. 

Treatment  and  Prognosis. — The  only  justifiable  treatment  of  epithe- 
lioma of  the  penis  is  an  immediate  excision  of  the  neoplasm  by  ampu- 
tation. The  line  of  amputation  should  always  be  wide  of  the  linnt  of 
the  disease.  If  the  induration  of  the  ulcer  is  well  defined,  and  is  lim- 
ited closely  to  the  margins  of  the  erosion,  the  amputation  may  be  made 
with  one  inch  of  sound  tissue  intervening.  If  the  inguinal  glands  are 
enlarged,  and  if  the  surgeon  has  reason  to  be  satisfied  that  the  enlarge- 
ment is  due  rather  to  inflammatory  engorgement  than  to  metastasis,  the 
operation  is  still  advisable,  and  the  prognosis  not  altogether  unfavorable. 
\Vhen  metastasis  of  the  glands  is  unmistakable,  amputation  may  be 
done  to  rid  the  patient  of  the  foul  and  ulcerating  mass,  although  a  favor- 
able prognosis  can  not  be  entertained.  In  the  earlier  development  of  the 
growth,  where  a  sufficient  extent  of  healthy  tissue  intervenes  between 
the  induration  and  the  line  of  excision,  amp)utation  offers  a  strong  hope 
of  permanent  relief.  In  the  earlier  period  of  development  of  the  ulcer, 
if  doubt  exists  as  to  its  character,  it  is  advisable  to  administer  the 

*  In  an  experience  of  several  years  in  attend.ance  at  Mount  Sinai  Hospital,  I  have  not  met 
witli  a  case  of  epithelioma  of  the  penis  in  an  individual  upon  wliom  in  early  life  circumcision 
had  been  performed. 


THE  PENIS.— SIMPLE  AMPUTATION.  637 

iodide  of  potassium,  together  with  protoiodide  of  mercury,  for  a  num- 
ber of  weeks.  In  this  way  the  differentiation  between  the  later  mani- 
festations of  syphilis  and  epithelioma  may  be  assured. 

Operation. — Amputation  of  the  penis  may  be  performed  by  two 
methods :  1,  simple  amputation  ;  2,  amputation  with  transplantation  of 
tlie  urethra  to  the  perineeiim.  In  the  selection  of  the  method,  the  opera- 
tor must  be  guided  by  the  nearness  of  the  disease  to  the  pubes  and  scro- 
tum. Ordinarily,  when  the  induration  is  limited  to  the  glans,  a  simple 
ani]>utation  may  be  made  at  a  jwint  about  one  inch  posterior  to  this. 
If  the  line  of  amputation  must  be  chosen  at  or  very  near  the  level  of 
the  pubes,  the  second  method  will  be  preferable,  for  the  reason  that  re- 
traction of  the  stump  will  always  occur,  and  the  urine  escaping  over  the 
scrotum  will  keep  up  a  constant  and  annoying  excoriation  and  condition 
of  uncleanliness.  In  the  operation  with  transplantation  of  the  urethra, 
the  urine  is  voided  in  the  squatting  posture,  and  escapes  freely  behind 
the  scrotum.* 

Sinqjle  Amputation. — Having  shaved  and  thoroughly  cleansed  the 
pubes,  scrotum,  and  penis,  throw  an  elastic  ligature  around  the  organ  at 
the  level  of  the  pubes.  If  the  line  of  amputation  is  very  near  the  liga- 
ture, this  may  be  prevented  from  slipping  l)y  transfixing  the  jienis  with 
a  large  needle  just  in  front  of  the  tourniquet.  Seize  the  mass  with  a 
double  hook,  and,  holding  it  steady,  with  a  long,  thin-bladed  knife  cut 
tlie  organ  smoothly  off  at  a  j^oint  at  least  one  inch  behind  the  disease. 
A  tenaculum  should  be  in  readiness  to  prevent  the  erectile  tissue  from 
retracting.  The  tube  of  the  urethra  should  now  be  dissected  up  for  half 
an  inch,  and  the  tissues  of  both  cavernous  bodies  again  divided  on  a 
level  with  the  point  to  which  the  dissection  of  the  spongiosum  has  been 
carried.  The  urethra  is  now  split  by  passing  the  knife  through  its  roof 
and  floor,  and  a  silk  suture  carried  through  the  end  of  each  lateral  half. 
A  thread  is  also  passed  through  the  dense  capsule  of  the  corpora  caver- 
nosa to  prevent  their  retraction  when  the  elastic  ligature  is  removed. 
All  vessels  which  may  be  recognized  before  loosening  the  rubber  band 
should  now  be  secured  with  catgut  ligatures,  and  the  remaining  bleed- 
ing points  caught  up  as  the  tourniquet  is  gradually  loosened.  The  su- 
tures passed  through  each  half  of  the  urethra  are  now  carried  through 
the  edge  of  the  incision  in  the  skin  to  which  it  is  sewed.  A  simple 
dressing  completes  the  operation. 

Humphrey's  Operation. — The  elastic  ligature  is  carried  around  the 
penis  close  up  to  the  level  of  the  pubes,  as  in  the  preceding  operation, 
and  the  organ  severed  as  near  the  ligature  as  possible.  The  vessels  in 
the  corpora  cavernosa  should  be  tied  at  once.  An  incision  should  now 
be  made  through  the  skin  along  the  under  surface  of  the  corpus  spon- 
giosum, back  to  and  splitting  through  the  base  of  the  scrotum,  so  as  to 
expose  the  tube  of  the  urethra  for  about  two  and  a  half  inches.     This 

*  I  have  performed  this,  the  operation  of  Humphrey,  three  times,  and  in  none  of  these 
patients  has  any  unpleasant  symptom  followed.  Two  of  the  cases  are  stUl,  under  observation 
three  years  after  the  operation. 


088 


A  TEXT-BOOK   ON   SURGERY. 


tube  is  carefully  dissected  out  from  its  attachment  beneatli  and  be- 
tween the  two  corpora  cavernosa  for  this  distance,  and  is  turned  down 
on  to  the  perinjeum  throuiih  the  slit  in  the  ijosterior  wall  of  tlie  scrotum. 
The  urethra  should  next  be  si)lit  aiouu'  the  median  line  of  its  loof  for  a 

distance  of  half  an 
inch  back  from  the 
end,  antl  the  edges 
stitched  to  the  mar- 
fjins  of  the  wound  in 
the  integument  of  the 
perinff-um.  The  oper- 
ation is  completed  by 
closing  the  i)osterior 
slit  through  the  scro- 
tum, and  stitching  the 
margin  of  the  wound 
in  the  skin  of  the  an- 
terior wall  of  the  scro- 
tum to  that  of  the 
belly  at  the  root  of 
the  penis,  so  as  to 
cover  in  and  include 
the  stump  of  the  am- 
putated corjtora  cav- 
ernosa. The  appear- 
ance of  the  ])arts  aft- 
er tills  operation  is 
shown  in  P^'ig.  046. 

Sarcoma  oi  the  pe- 
nis is  exceed  ingl  y  rare. 
It  may  be  recognized 
by  its  rapid  development,  the  absence  of  glandular  enlargement,  the  gen- 
eral invasion  of  the  cavernous  bodies — in  certain  cases  producing  a  con- 
tinuous and  painful  erection  of  the  organ — and  by  its  resemblance  to  the 
well-known  appearance  and  behavior  of  sarcomatous  tumors  in  other 
portions  of  the  body.  The  treatment  should  consist  in  immediate  am- 
putation. 

FJiimosis,  or  inaliility  to  retract  the  prepuce  behind  the  corona  glan- 
dis,  is  a  frecxuent  conditifin  of  childhood,  and  occasionally  met  with  in 
adult  life.  It  is  both  a  congenital  and  an  acquired  affection,  and  may  be 
partial  or  complete.  The  prepuce  may  be  adherent  to  the  glar.s,  or 
phimosis  may  exist  without  adhe.sions,  the  opening  in  the  foreskin 
being  so  narrow  that  retraction  is  impossible.  A  prepuce  ordinarily 
retractile  may  become  irretractible  as  a  result  of  any  inflammatory  pro- 
cess of  the  glans  and  foreskin.  This  condition  is  not  infrequently  met 
with  in  gonorrhoea  and  with  chancroid. 

Congenital  phimosis  is  an  unfortunate  affection,  preventing  perfect 
cleanliness  by  retention  and  decomposition  of   the  retained  secretions 


FiQ.  64ii. —  Humphrey's  opcratinn.     fFrnm  a  ca.«e  of  the  .luthor's,  at 
Mount  Siuai  llo^llitIlhJ 


THE  PENIS— PHIMOSIS.  639 

and  nrine,  and  inducing  a  condition  of  irritation  whicli  it  were  better  to 
avoid  by  timely  ojaerative  interference.  Inflammatory  or  acquired  jjhi- 
mosis  always  requires  careful  attention,  and  very  frequently  a  surgical 
()I)eiation,  to  prevent  gangrene  or  to  expose  a  subprepiitial  chancroid. 

The  operative  measures  may  include :  1,  amputation  of  the  prepuce 
(circumcision") ;  2,  dilatation  of  the  preiiutial  orifice  with  forced  retrac- 
tion ;  3,  incision  of  the  anterior  portion  of  the  prepuce  and  retraction. 

The  first  of  these  procedures  should  be  preferred  in  all  cases  in  which 
there  is  no  inflammatory  process  present,  while  the  latter  is  advisable  in 
phimosis  with  acute  balano-posthitis. 

Operation. — In  adults,  circumcision  may  be  done  with  perfect  free- 
dom from  pain  by  the  proper  employment  of  cocaine.  In  children  under 
six  years  of  age,  chloroform  narcosis  is  advisable. 

In  adults,  proceed  as  follows :  Cleanse  the  parts  to  be  operated  upon 
with  l-to-5()00  sublimate  solution,  and  throw  an  elastic  ligature  around 
the  penis  at  the  level  of  the  pubis.  From  ill  xx-xxx  of  a  4-i3er-cent 
cocaine  solution  are  now  injected  by  inserting  the  needle  at  the  margins 
of  the  preputial  orifice,  and  carrying  it  back  between  the  mucous  mem- 
brane and  integument  of  the  prepxice  a  little  behind  the  proposed  line 
of  section.  In  the  middle  of  the  dorsum  three  or  four  minims  are  forced 
out  of  the  syringe,  the  needle  partially  withdrawn  and  carried  a  half- 
inch  to  right  and  left  of  this  point,  and  a  like  quantity  is  injected,  and 
so  on  until  the  entire  line  of  amputation  is  anjesthetized.  As  a  rule,  it 
will  suffice  to  insert  the  needle  once  in  the  median  line  above,  and  once 
at  the  frpenum,  and  from  these  two  locations  it  may  be  thrust  beneath 
the  skin  to  either  side  until  the  prepuce  is  completely  encircled. 

In  selecting  the  line  of  incision,  the  best  rule  is  to  aUow  the  parts  to 
assume  their  normal  relations,  and  mark  the  foreskin,  by  repeated 
punctures  with  the  scalpel,  i)arallel  with  and  one  fourth  of  an  inch  an- 
terior to  the  outline  of  the  corona  of  the  glans.  A  dull-pointed,  grooved 
director  should  now  be  passed  between  the  upper  siirface  of  the  glans 
and  the  prepuce,  in  the  median  line,  until  the  point  is  at  the  line  of 
amputation.  A  sharp-pointed  bistoury  is  next  slipped  along  the  groove 
in  the  dii'ector,  thrust  through,  and  the  foreskin  si:)lit  by  cutting  from 


Fio.  647.  Fig.  648. 

behind  forward  (Fig.  647).  Or  this  incision  may  be  made  from  be- 
fore backward  with  a  pair  of  straight  scissors.  The  edges  of  the  fla]is 
are  now  seized  with  a  pair  of  mouse-tooth  fixation-forceps,  and  trimmed 


640 


A  TEXT-BOOK   ON  SURGERY. 


off   witli  scissors,    being  careful   to  follow  the  line  already  indicated 

(Fig.  048). 

Wlicn  these  incisions  are  conii)leted,  it  will  be  observetl  that  the  edge 

of  the  divided  mucous  membrane  remains  at  the  level  of  the  incision — 

namely,  a  quarter  of  an  inch  in  front  of  the  outline  of  the  corona  glan- 

dis — while  the  skin  retracts  beyond  the  corona.     The  mucous  membrane 

should  now  be  turned  back,  and  its  edge 
stitched  to  that  of  the  incision  in  the  skin. 
Fine  catgut  should  be  used,  and  an  interrupt- 
ed or  continuous  suture  employed.  The  for- 
mer is  somewhat  more  accurate,  although  it 
requires  much  more  time  in  its  insertion  than 
the  latter.  It  is  important,  in  tlie  effort  to 
secure  immediate  union,  tliat  at  all  points  the 
apju'oximation  is  carefully  made  between  the 
margins  of  the  integument  and  mucous  mem- 
brane.    After  the  sutures  are  inserted,  the 

mucous  membrane  rolls  back,   leaving  the  stitches  behind  the  corona 

(Fig.  649).     The  elastic  ligature  is  now 

removed,  and  a  light  dressing  applied 

over  the  line  of  sutures.     This  operation 

is  entirely  bloodless.    The  patient  should 

be  directed  to  prevent  the  urine  from 


Fio.  649. — (.After  Malgaigne.) 


Fig.  650. — GirJner's  pliimosis-lbrceps 


getting  into  the  wound.  Tlie  sutures 
disappear  by  absorption,  and  the  union 
is  complete  in  from  four  to  ten  days. 

When  the  prepuce  is  adherent  to  the 
glans,  it  will  be  found  impossible  to  in- 
troduce the  grooved  director  as  above  unless  the  adhe.sions  are  first 

broken  up.  Under  these 
conditions,  the  following 
oi)eration  should  be  per- 
foiined  :  Carry  the  phi- 
mosis-f creeps  (Fig.  6r)()) 
into  the  oi)ening  of  the 
pi'epuce,  and  allow  the 
blades  to  expand  so  that 
the  hooklets  at  the  tip 
will  catch  in  the  mucous 
membrane.  The  fore- 
I  **,:.»—--"-  1  \        \  \  skin  is  now  drawn  well 

to  the  front  by  an  assist- 
ant, while  the  operator 
slips  the  thumb  and  fin- 
ger of  the  left  hand  along 
the  penis  and  grasps  the 
foreskin  just  in  front  of  the  meatus.  In  young  children,  considerable  care 
is  necessarj'  to  prevent  cutting  off  a  portion  of  the  glans  with  the  pre- 


ULCERS  OF    THE  PENIS.  641 

puce.  Tlie  foreskin  is  next  amputated  with  the  scissors  just  in  front  of 
^he  finger  and  thumb  (Pig.  651).  As  retraction  takes  place,  it  will  be  seen 
that  the  line  of  section  in  the  skin  is  near  the  corona,  while  that  in  the 
mucous  membrane  is  only  a  little  back  of  the  meatus.  This  should  be 
seized  with  the  mouse-tooth  forceps,  and  the  adhesions  broken  loose  or 
divided  with  the  scissors.  The  mucous  lining  should  now  be  j^ared  back 
to  a  sufficient  distance,  and,  if  necessary,  a  second  division  of  the  pre- 
puce made.     The  sutures  are  ajiplied  as  in  the  preceding  opei'ation. 

Dilatation  or  ditulsion  of  the  prepuce  is  rarely,  if  ever,  indicated. 
It  is  performed  by  introducing  the  point  of  a  small,  closed  dressing-for- 
ceps into  the  opening  of  the  foreskin,  and  stretching  or  tearing  this  by 
forced  separation  of  the  blades.  The  operation  is  completed  by  retract- 
ing the  jn-epuce  and  breaking  up  all  adhesions.  In  the  after-treatment 
it  is  essential  to  move  the  foreskin  back  and  forth  over  the  glans  once 
or  twice  daily  to  prevent  the  re-formation  of  adhesions. 

Incision  limited  to  the  anterior  half-inch  of  the  foreskin,  and  in  the 
median  line  of  the  dorsum,  is  a  more  advisable  operation  when  circum- 
cision is  contraindicated.     Retraction  should  be  immediately  etfected. 

Ulcers  of  the  Penis. — Sores  may  occur  upon  the  integument  of  the 
penis,  usually  near  the  prepuce ;  upon  the  mucous  lining  of  the  fore- 
skin ;  the  glans  ;  within  the  meatus ;  and  along  the  urethra.  Venereal 
sores  are  occasionally  met  with  upon  the  integiiment  of  the  scrotum, 
alidomen,  perin.cura,  and  thighs.  Ulcers  of  the  penis  only  will  be  con- 
sidered here.  They  ai'e  divisible  into  two  classes — namely,  the  non- 
specific and  the  specific  ulcer.  To  the  former  belong  the  sores  which 
follow  aln-asions  and  the  eruption  of  herpes.  They  are  more  or  less 
phagedenic  in  character,  the  extent  and  rapidity  of  the  process  of  ne- 
crobiosis being  due  to  the  degree  of  virulence  of  the  inoculating  pus- 
corpuscles,  the  thoroughness  of  the  inoculation,  and  the  impoverished 
condition  of  the  tissues  attacked.  The  chancroid  belongs  to  this  group. 
In  the  second  class  belongs  the  specific  ulcer  of  syphilis. 

Ko a- specific  Ulcers. — A  simple  ulcer  of  the  penis  is  extremely  rare. 
It  may  occur  here,  as  in  other  parts  of  the  body,  as  a  result  of  trauma- 
tism, or  an  inflammatory  process  not  due  to  the  inoculation  of  a  virus. 
Thus,  the  molecular  death  of  a  variable  extent  of  tissue  may  follow  a 
simple  abrasion  if  the  part  involved  is  not  kept  free  from  all  irritation, 
an;l  if  there  prevails  a  condition  of  imj^aired  nutrition,  in  which,  as  is 
well  known,  the  tissues  yield  readily  to  the  destructive  process.  Under 
more  healthful  conditions,  an  abrasion  of  the  glans  or  prepuce  under- 
goes the  simple  process  of  repair  seen  in  similar  lesions  of  the  integu- 
ment and  mucous  surfaces  elsewhere.  Abra.sions  nsuaUj'  occur  on  the 
sides  of  the  penis,  close  to  the  attachment  of  the  prepuce,  just  behind 
the  corona  or  near  the  frsenum.  The  glans  is  rarely  involved,  although 
the  meatus,  especially  at  its  lower  angle,  may  be  torn.  Bleeding  sufh- 
cient  to  attract  the  attention  of  the  patient  is  rare,  unless  extensive 
laceration  has  occurred. 

The  ulcer  of  herpes  is  usually  situated  u])on  the  surface  of  tlie  mu- 
cous lining  of  the  prepuce,  less  frequently  upon  its  cutaneous  surface, 


642  A  TEXT-BOOK  ON   SURGERY. 

and  the  pclans.  It  begins  as  a  vesicular  eruption.  There  may  be  one  (tr 
many.  Multiple  herpetic  vesicles  may  be  scattered  or  in  clusters,  linear, 
semilunar,  or  circular  in  arrangement.  In  the  recent  state  the  herpetic 
vesicle  is  round  at  its  base,  measuring  I'rom  (me  twelfth  to  one  twenty- 
fifth  of  an  inch  in  width.  It  consists  of  a  thin  investing  membrane  rest- 
ing ui)(m  a  slightly  red  and  irritated  base,  and  containing  a  clear,  serous 
fluid,  which  often  escapes  by  rupture  of  the  meml)raue  before  the  vesicle 
is  observed.  Upon  the  skin  they  rapidly  drj^  on  account  of  evaporation 
of  the  fluid  contents,  and  the  floor  of  the  patch  becomes  covered  over 
with  a  light  incrustation.  Upon  the  mucous  and  moist  surfaces,  in- 
crustation does  not  occur.  The  circumference  of  the  base  exposed  after 
rupture  of  the  vesicle  is  usually  round,  Avith  well-defined  walls  leading 
perpendicularly  down  to  the  bottom  of  a  shallow  excavation. 

In  typical  cases  of  genital  herpes,  the  morbid  process  ends  here, 
the  sore  healing  without  supi)uration.  Not  infrequently,  however,  the 
floor  becomes  covered  with  a  layer  of  pus,  the  walls  are  undermined 
and  break  down,  forming  an  ulcer  which  is  phagedenic  in  character. 
The  character  of  the  jiain  varies.  In  some  instances  there  is  a  sting- 
ing, burning,  sensation  felt  in  the  part  affected  ;  in  others  there  exists 
total  insensibility. 

Herpes  is  a  neurosis  due  to  a  local  irritation  of  the  nerve  termina- 
tions in  the  part  attacked.  In  some  instances  a  severe  neuralgia  of  the 
branches  of  the  sacral  or  lumbar  plexuses  exists  at  the  time  of  the  erup- 
tion on  the  glans  and  prepuce.  Uncleanliness  is  a  frequent  cause  of  this 
disease.  Any  irritation  of  the  glans  or  prepuce  may  induce  it,  and  one 
attack  is  apt  to  be  followed  by  a  second. 

In  mild  and  ordinary  cases  it  runs  its  course  in  from  ten  days  to  two 
or  three  weeks.  In  other  forms,  especially  when  inoculation  occurs,  it 
may  last  for  a  number  of  weeks,  and  is  usually  complicated  by  lymi)han- 
gitis  and  adenitis. 

Phagedenic  ulcer  of  the  genital  organs  was  formerly  held  to  be  the 
result  of  the  inoculation  of  a  specific  poison — the  virus  of  "chancroid"'; 
but,  since  ulcers  which  in  appearance  and  behavior  do  not  differ  from 
the  so-called  chancroidal  ulcer  have  been  produced  by  inoculation  with 
corpuscles  taken  from  the  pustules  of  acne,  from  gonorrhcral  pus,  etc., 
the  specific  nature  of  this  virus  can  not  be  maintained.  Even  the  spe- 
cific ulcer  of  syphilis  will,  as  a  result  of  repeated  and  prolonged  irrita- 
tion, take  on  a  phagedenic  character. 

This  ulcer  results  most  fi-equently  from  direct  contagion,  the  pus-cor- 
puscles which  contain  the  virus  being  lodged  in  an  abrasion  of  the  in- 
tegument, prepuce,  or  glans  The  period  of  incubation — that  is,  the 
length  of  time  between  the  date  of  the  contact  and  the  recognition  of 
the  sore — will  vary  in  different  individuals.  It  has  been  seen  within 
twenty-four  hours,  and,  in  rare  instances,  as  much  as  twenry  days  have 
elapsed.  In  a  very  large  majority  of  cases  the  intlammation  is  observed 
within  the  first  nine  days  after  the  inoculation.  The  rapidity  of  its  ap- 
pearance depends  in  part  i;pon  the  quantity  and  vinilence  of  the  pus, 
but  chiefly  upon  the  thoroughness  with  which  it  is  brought  into  con- 


ULCERS   OF  THE   PENIS.  643 

tart  Avith  the  tissues  in  an  abrasion.  The  sjuead  of  the  ulcer  and  its 
phagedenic  character  also  depend  upon  the  virulence  of  the  poison  and 
the  condition  of  the  tissues  at  the  time  of  the  invasion.  The  ulcer  is 
usually  located  on  the  side  of  the  penis,  just  behind  the  corona  glandis 
at  the  preputial  attachment,  at  the  points  where  abrasions  are  most 
frequent.  It  may  be  on  the  cutaneous  surface  of  the  prepuce,  upon 
the  body  of  the  i:)enis,  the  scrotum,  or  within  the  meatus.  There  may 
be  one  or  more,  owing  to  the  number  of  abrasions  and  the  distribu- 
tion of  the  virus.  A  single  ulcer  may  result  from  the  confluence  of  sev- 
eral contiguous  points  of  inoculation.  It  is  first  noticed  as  a  light  red- 
ness or  flush,  iisuaUy  cu'cular  or  elliptical  in  shape,  or,  if  the  abrasion 
is  irregular  in  outline,  it  will  confoi-m  to  this.  Within  a  few  hours  after 
the  ajipearance  of  the  redness,  its  center  becomes  elevated  and  a  pustule 
is  formed,  which  soon  breaks  down,  discharging  a  small  quantity  of 
matter. 

If  the  sore  is  not  seen  early,  the  pustule  may  escape  observation. 
"When  the  inoculation  occurs  upon  a  surface  denuded  of  its  mucous  mem- 
brane or  epidermis,  a  pustule  is  not  formed.  The  walls  of  a  phage- 
denic ulcer  are  usually  precipitous.  At  times  the  superficial  layers  of 
the  skin  resist  disintegration  longer  than  the  deeper  layers  and  subcu- 
taneous tissues,  giving  the  edges  an  undennined  ajipearance.  It  tends 
to  spread  in  width  rather  than  in  depth,  although  in  a  certain  propor- 
tion of  cases  extensive  destruction  of  tissue  may  occur  in  all  directions. 
The  floor  of  the  ulcer  is  covered  with  pus  and  broken-down  tissues  in 
various  stages  of  decomposition.  A  small  quantity  of  matter  of  creamy 
consistence  may  be  removed  with  a  pellet  of  cotton.  A  membrane  or 
film  of  a  yellowish-brown  color  usually  adheres  to  the  floor  with  con- 
siderable tenacity. 

A  zone  of  redness  extends  along  the  edges  of  the  ulcer  in  advance  of 
the  tissue-destruction.  In  many  iilcers  this  is  not  more  than  a  line  in 
width.  If  the  sore  is  subjected  to  irritation,  the  intiammator\'  redness 
and  induration  may  spread  widely  into  the  surrounding  tissues. 

Pain,  which  is  always  present,  varies,  as  a  rale,  %vith  the  extent  of 
the  inflammatory  process. 

In  a  typical  phagedenic  ulcer  of  the  penis,  lymphangitis  and  adenitis 
of  the  inguinal  glands  are  always  present  in  a  varying  degree.  In  the  sim- 
l)ler  foiTus,  adenitis  does  not  occur,  although  the  lymphatic  channels  in 
the  neighliorhood  of  the  sore  may  be  involved.  Inguinal  bubo  is  always 
a  painful  complication.  It  may  be  lateral  or  liUateral.  If  the  sore  is  in 
the  median  line,  or  if  there  are  ulcers  on  both  sides,  both  groups  of 
glands  will  be  affected.  Suppuration  of  the  inguinal  bubo  of  phagedenic 
ulcer  is  not  uncommon.  The  violence  of  the  inflammatory  process  here 
is  subject  to  the  same  conditions  as  given  for  the  primary  ulcei*.  One 
or  more  glands  may  be  involved  and  suppurate.  In  severe  adenitis,  the 
inflammation  extends  to  the  tissues  immediately  surrounding  tiie  glands. 
The  mass  ai)peai"s  as  one  large  swelling,  over  which  the  integument  is 
red  and  oodematous.  and  to  which  it  is  adherent.  Phagedenic  bubo  is 
apt  to  follow  a  virulent  phagedenic  ulcer  of  the  penis. 


644  A  TEXT-BOOK  ON  SURGERY. 

Treatment. —?^\mYi}e  ulcer  of  the  penis,  if  left  witliont  interference, 
usually  lieals  williiri  ;i  few  weeks ;  the  ulcer  of  herpes  is  usually  more 
obstinate.  The  process  of  repair  may  bo  tjreatly  facilitated  by  a  careful 
removal  of  all  sources  of  irritation.  Strict  cleanliness  is  essential,  no 
matter  what  form  the  ulcer  may  assume.  Soaking  the  jiart  in  warm 
black  wash  (calnnicl  3  j  to  lime-water  Oj)  two  or  three  times  a  day  is  an 
excellent  method  of  treatment.  The  local  use  of  liquor  plunibi  sul)aceta- 
tis  dilutum  is  also  advisable. 

In  addition  to  the  foregoinj;,  it  is  essential  to  keep  the  sore  uncov- 
ered by  the  prepuce,  which  should  be  worn  back  behind  the  corona. 
Circumcision  may  at  times  become  necessary  to  obtain  a  permanent  cure. 
If  the  simpler  remedies  just  given  do  not  succeed,  the  local  use  of  the 
nitrate-of-silver  jjencil  is  indicated. 

In  phagedenic  ulcer,  as  a  rule,  more  vigorous  measures  are  necessary. 
The  severity  in  local  treatment  will  depend,  however,  upon  the  rajjidity 
of  molecular  death  which  the  poison  is  causing  in  the  tissues.  If  its 
progress  is  slow,  and  the  inflammation  mild  in  character,  recovery  may 
be  brought  about  by  the  treatment  laid  down  for  simple  and  herpetic 
ulcer.  If  within  the  first  few  days  of  its  appearance  the  spread  of  the 
sore  is  rapid,  or  if,  when  first  brought  to  the  notice  of  the  i)hysician,  it 
is  more  than  a  quarter  of  an  inch  in  diameter,  and  the  zone  of  redness 
spreads  well  out  into  the  tissues,  it  should  be  treated  as  follows :  By  the 
introduction  of  a  delicate  hypodermic  needle  through  the  sound  tissues, 
after  which  its  point  should  be  carried  under  the  base  of  the  ulcer,  from 
fifteen  to  twenty  minims  of  a  4-pei'-cent  solution  of  cocaine  should  be 
injected,  by  which  means  complete  ansesthesia  may  be  secured.  The 
pus  should  now  be  removed  from  the  bottom  of  the  sore  with  a  pellet 
of  absorbent  cotton  on  the  end  of  a  small  piece  of  wood.  The  parts  im- 
mediately about  the  ulcer  slioidd  be  coated  over  with  vaseline  or  oil, 
to  protect  them  from  excoriation.  A  small  quantity  of  carbonate  of 
soda  should  be  on  hand  to  neutralize  any  excess  of  acid.  In  a]i])lying 
pure  nitric  acid,  the  ulcer  should,  if  possible,  be  held  so  that  it  will  con- 
tain the  acid  without  letting  it  run  over  the  edges.  It  is  best  applied 
by  means  of  a  wooden  match  or  tooth-pick  dipped  in  the  acid,  and  the 
point  immediately  carried  into  the  floor  of  the  ulcer.  It  should  be  con- 
veyed into  every  portion  of  the  sore,  and  allowed  to  remain  in  contact 
with  the  virus  for  one  or  two  minutes.  The  excess  may  now  be  soaked 
out  with  the  cotton  pellets,  and  the  ulcer  filled  with  soda.  A  piece  of 
lint  moistened  in  vaseline  will  serve  as  a  dressing.  When  nitric  acid  can 
not  be  had,  the  actual  cautery  should  be  employed. 

Iodoform  may  be  dispensed  with,  on  account  of  the  disagreeable  odor 
of  this  substance. 

When  phagedenic  ulcer  occurs  beneath  an  irretractible  prepuce,  this 
should  be  incised  and  the  sore  treated  as  above.  Ulcer  of  the  meatus 
should  also  be  bui'ned  with  nitric  acid.  Corai^lete  rest  is  essential,  and 
constitutional  measures  looking  to  the  improved  nutrition  of  the  tissues 
are  strongly  indicated.  If  suppuration  occurs  in  the  glands  of  the  in- 
guinal region,   free   incision  should  be  made  and  free  drainage  estab- 


ULCERS   OF  THE   PENIS— SYPHILIS.  645 

lifhecl.  Phagedenic  bubo  should  be  treated  ia  the  same  manner  as  the 
pliagedenic  ulcer. 

The  Specific  Ulcer  {Cliancre) — S>/ph/lis. — Syphilis  is  a  disease  affect- 
ing in  a  varying  degree  the  nutrition  of  all  the  tissues  of  the  human 
body.  It  is  caused  by  the  introduction  into  the  blood  of  a  specific  virus. 
In  practice,  two  distinct  forms  are  met  with,  namely — the  acquired  and 
the  inlieritcd. 

Acquired  syjAilis  ensues  when  the  specific  virus  is  can-ied  into  the 
lymph  or  blood-channels  of  a  human  being  not  syphilitic  at  the  time 
of  inoculation. 

Of  the  physical  or  chemical  properties  of  this  virus  practically  noth- 
ing is  known.  The  claims  that  it  exists  as  a  dwarfed  or  crippled  leuco- 
cyte, a  fungus,  a  special  form  of  pus,  a  peculiar  bacillus,  etc.,  have  not 
been  substantiated  nor  accepted. 

"While  it  is  generally  believed  that  an  abrasion  of  the  skin  or  mucous 
surface  is  essential  to  tlie  absorption  of  the  syphilitic  virus,  it  is  ex- 
tremely probable  that,  if  it  is  brought  and  kept  in  contact  with  the  thin 
unbroken  skin  or  mucous  membranes,  absorption  may  occur.  A  disease 
the  germs  of  which  are  transported  within  the  spermatic  elements,  and 
with  such  potency  that  the  impregnated  ovum  is  affected,  can,  under 
favorable  conditions,  in  all  i^robabUity  be  transmitted  from  unbroken 
cutaneous  or  mucous  surfaces  through  wliich  it  is  demonstral)]e  that 
the  absorption  of  other  elements  occurs. 

The  chief  source  of  the  contagion  is  in  the  fluid  which  transudes  from 
the  surface  of  the  initial  lesion  or  ulcer  (chancre),  and,  next  in  order,  that 
from  mucous  patches.  The  blood  of  a  sj'philitic  patient  also  carries  the 
poison  and  produces  the  disease  if  injected  into  or  inoculated  upon  the 
tissues  of  another.  The  same  is  true  of  the  matter  or  fluid  from  the 
cutaneous  lesion  of  the  secondary  stage  of  syphilis.  It  is  doubtful  if 
tlie  lesions  of  tertiary  syphilis  are  capable  of  reprodiicing  the  disease. 

Saliva  from  a  syphilitic  subject,  unmixed  with  the  discharge  from 
mucous  i)atches,  fails  to  produce  syphilis.  Seminal  fluid  from  a  syphi- 
litic man,  in  any  of  the  stages  of  the  disease,  is  held  to  be  not  directly 
contagious.  Howevei",  the  mother  may  acquire  the  disease  from  a  child 
in  utero,  the  child  being  syphilitic  from  the  spermatozoa.  Milk  from  a 
woman  in  any  stage  of  syphilis  will  not  produce  the  disease  if  injected 
into  the  tissues  or  ingested  as  food. 

The  transudation  from  a  fissure  in  the  nipple  of  a  sypliilitic  nurse 
\\\\\,  if  lodged  in  an  abrasion  npon  the  lips,  tongue,  or  buccal  wall  of 
the  child,  produce  the  sj>ecific  disease  in  a  non-syphilitic  subject.  On 
the  other  hand,  a  syphilitic  child  may  inoculate  a  healthy  nurse.  The 
urine,  tears,  and  sweat  of  syphilitic  patients  do  not  convey  the  specific 
virus.  Pus  from  a  vaccine  pustule  on  a  syphilitic  subject  does  not  con- 
vey the  virus  of  this  disease  even  when  the  vaccination  is  successful.  If, 
however,  blood  or  the  fluid  from  any  early  syphilitic  lesion  is  mingled 
with  the  pus,  syphilis  results. 

While  the  most  frequent  seat  of  inoculation  is  upon  the  genital  or- 
gans, or  in  their  immediate  vicinity,  it  may  occur  at  any  part  of  the 


646  A  TEXT-BOOR  ON   SUIKiERY. 

body.  The  contagion  may  be  direct  or  indirect.  In  the  former,  the 
virus  of  a  specific  ulcer  is  brought  directly  in  contact  with  an  abrasion 
upon  a  non-syphilitic  subject.  In  the  latter,  the  poison  adheres  to  some 
intermediate  agent,  and  thence  is  conveyed  to  the  abrasion.* 

The  clinical  history  of  a  typical  case  of  acquired  sy])hilis  left  without 
treatment,  and  in  a  certain  proportion  of  cases  in  which  treatment  is  in- 
stituted, is  divided  by  usage  into  three  stages — primary,  secondary,  and 
tertiary.  In  a  majority  of  cases,  when  properly  managed,  the  later  mani- 
festations may  be  eliminated,  and  the  secondary  stage  made  shorter  and 
less  severe. 

The  priman/  stage  includes:  1,  absoi-ption  of  the  virus  ;  2,  the  ulcer; 
3,  local  lymphangitis  and  adenitis. 

The  symptoms  which  belong  to  the  second  stage  are  the  cutaneous 
eruptions,  mucous  patches,  fever,  arteritis,  condylomata,  alopecia,  iritis, 
and  general  adenitis.  In  the  tertiary  stage,  the  pathological  changes  are 
chietiy  confined  to  the  arteries,  viscera,  bones,  the  integument,  and  the 
subcutaneous  and  submucous  connective  tissues.  This  is  the  period  of 
gummy  tumors,  connective- tissue  formations,  arterial  occlusion,  and  deep 
ulcers  of  the  skin  and  mucous  membranes. 

The  usual  duration  of  the  first  stage  is  from  six  to  nine  weeks.  Sec- 
ondary symptoms  may,  however,  appear  at  the  fifth  or  sixth  week  from 
the  date  of  inoculation.  On  the  other  liand,  in  rare  instances,  they  may 
be  delayed  to  between  the  third  and  sixth  month.  The  limitation  of  the 
stages  of  this  disease  is  in  great  jjart  arbitrary. 

The  duration  of  the  second  stage  varies  from  the  fifth  or  sixth  week 
(or  in  delayed  cases  the  sixth  month  after  contact)  to  about  the  end  of 
the  first  year  after  the  inoculation. 

The  tertiary  stage  begins  at  the  end  of  the  preceding  stage,  and  may 
last  indefinitely. 

First  Stage. — When  the  specific  virus  is  brought  in  contact  with  a 
broken  cutaneous  or  mucous  surface,  absorption  may  begin  at  once  or 
be  delayed  for  a  considerable  period.  The  abrasion  may  be  so  insignifi- 
cant that  the  patient's  attention  is  not  attracted  to  it,  and,  although  the 
virus  is  lodged  in  it,  it  may  heal  over  within  a  few  days.  If  subjected 
to  irritation  by  friction,  or  the  simultaneous  inoculation  with  the  virus 
of  phagedenic  ulcer  or  other  virus,  inflammation  supervenes,  and  an  ulcer 
more  or  less  phagedenic  in  character  appears. 

Absorption  takes  place  chiefly  through  the  lymphatics.  It  may  occur 
through  the  blood-vessels,  and  it  is  possible  that  in  those  cases  in  whicli 
constitutional  symptoms  appear  with  great  rapidity  and  severity,  the 
dissemination  of  the  virus  takes  place  in  this  way. 

The  rapidity  of  lymphatic  absorption  varies.  There  is  usually  a  pe- 
riod of  about  three  weeks  from  the  time  of  lodgment  of  the  virus  untU 

*  la  one  of  my  c.nses  the  inocalation  occurred  in  a  fissure  of  tlie  lip  in  the  person  of  a  mer- 
chant wlio  was  using  a  glass  in  common  with  a  customer  in  samplin<r  wines.  In  1883  a  patient 
presented  himself  at  the  clinic  who  h.id  had  a  specific  ulcer  and  syphilis  resulting  from  being 
tattooed  upon  the  arm.  The  operator  moistened  the  point  of  the  needle  with  saliva  in  wliich 
the  virus  from  raucous  patches  was  mingled,  and  thus  conveyed  it  into  tlie  integument. 


SYPHILIS.  647 

the  local  inflammatory  process  is  recognized.  That  the  specific  virus 
has  passed  into  the  neighboring  lymph-channels  before  the  appearance 
of  the  ulcer  (chancre)  seems  satisfactorily  proved  in  the  repeated  ex- 
jjeriment  of  freely  excising  the  initial  lesion  at  its  earliest  appearance, 
in  which  cases  constitutional  infection  was  not  retarded  or  prevented. 

The  ulcer  of  syphilis  always  appears  at  the  point  where  absorption 
of  the  virus  took  place.  From  the  inoculation  to  its  appearance,  the 
lapse  of  time  is  usually  about  three  weeks — not  less  than  ten  days  ;  occa- 
sionally delayed  as  many  weeks.  Its  duration  varies  from  two  to  ten 
weeks,  occasionally  longer.  It  often  begins  as  a  small  papule,  from  the 
covering  of  which  a  clear  serum  escapes,  or  from  the  beginning  it  may 
exist  as  an  erosion.  There  may  be  one  or  many,  owing  to  the  number 
of  points  simultaneously  inoculated. 

An  uncomplicated  initial  lesion,  not  subjected  to  irritation,  does  not 
tend  to  ulcerate.  It  is  visually  circular  or  oval  in  outline,  is  shallow,  in- 
creasing gradually  in  depth  from  the  periphery  toward  the  center,  and 
its  surface  is  covered  with  a  yellow  serous  transudation. 

Grasped  between  the  thumb  and  finger,  it  is  found  to  be  indurated, 
not  painful.  The  induration  is  closely  limited  to  the  sore,  and  termi- 
nates rather  abruptly,  not  fading  off  gradually  in  a  wide  infiltration  of 
the  skin  or  neighboring  tissues. 

When  the  specific  ulcer  of  syphilis  is  inoculated  with  a  virus  which 
induces  phagedena,  its  peculiar  character  is  lost,  and  it  becomes  in  ap- 
pearance and  behavior  a  non-specific  sore.  If  from  friction  or  the  appli- 
cation of  corrosive  substances,  or  the  cautery,  an  acute  inflammation  is 
precipitated,  the  specific  character  of  the  lesion  also  disappears. 

Local  lymphangitis  and  adenitis  always  occur  in  syphilis  during  the 
formation  and  existence  of  the  initial  ulcer.  Commencing  in  the  lymph- 
cliannels  immediately  around  the  lesion,  the  process  travels  in  the  direc- 
tion of  tlie  nearest  glands.  If  the  sore  is  well  on  one  side,  the  glands  of 
that  side  are  usually  first  affected.  "When  situated  in  the  median  line, 
or  if  ulcers  exist  on  both  sides,  the  adenitis  is  apt  to  be  bilateral.  In 
very  exceptional  cases,  ulcer  of  one  side  is  followed  by  unilateral  ade- 
nitis on  the  opposite  side  of  the  body.  Dating  from  the  appearance  of 
the  sore,  from  eight  to  fourteen  days  usually  elapse  before  enlargement 
of  the  inguinal  glands  is  noticed.  Less  frequently,  three  or  four  weeks 
intervene. 

From  one  to  seven  distinct  glandular  nodules  may  be  felt.  They  ai'e 
hard,  yet  slightly  elastic  to  the  touch,  not  painful  under  ordinary  press- 
ure, and  freely  movable  beneath  the  skin.  The  size  varies  from  those 
whicli  are  so  small  as  scarcely  to  be  recognized  up  to  a  half-inch  or  more 
in  diameter.  There  is  no  peiiadenitis,  and,  unless  an  acute  or  phage- 
denic inflammatory  j^rocess  is  superadded,  the  glands  do  not  become 
matted  together  in  one  hard,  painful  lump,  nor  does  the  integument  be- 
come red  and  painful,  as  in  the  adenitis  of  phagedenic  ulcer  or  gonor- 
rhopa. 

The  primary  adenitis  continues  into  the  second  stage,  in  which  indu- 
ration of  the  glands  is  general. 


648  A  TFA'T-r.OOK   OX  SURGERY. 

When  the  ulcer  is  situated  upon  tlie  lips,  tongue,  or  mouth,  the  sub- 
niiixillarv  plexus  l)oc()mes  enlarged.  Adenitis  of  the  ei)itr()cldear  and 
axillary  glands  follows  inoculation  upon  the  lingers,  hand,  or  forearm. 

Second  Stage. — Cutaneous  and  mucous  lesions,  alopecia,  fever,  liead- 
ache,  arteritis,  IvTnjdiangitis,  adenitis,  iritis,  and  osteitis. 

The  cutaneous  k'sions  of  syphilis  {si/philldes)  may  be  macular, 
pa])ular,  vesicular,  ])ustular,  and  tubercular.  Of  these  forms  of  erup- 
tion, some  are  peculiar  to  the  secondary  period,  others  to  the  tertiary, 
while,  as  will  lie  seen,  some  are  met  with  in  both  the  second  ;ind  third 
stages. 

The  macular  syphilide  is  usually  first  seen  occurring  as  indistinct 
spots  or  stains,  not  elevated,  and  varying  from  a  light  red  to  a  slate  or 
copper  color.  They  appear  very  frequently  at  the  limit  of  the  first  stage 
of  syphilis,  about  the  sixth  or  seventh  week  after  the  ulcer  occurs,  but 
often  later  than  this  period.  The  portion  of  the  body  where  the  macuhe 
are  usually  fii'st  seen  is  upon  the  abdomen,  whence  they  may  extend  over 
the  entire  cutaneous  surface.  In  size  they  vary  from  a  pin-head  to  round 
or  oval  spots  a  half-inch  ov  more  in  diameter. 

The  papnlar  syphilide  occurs  in  several  forms  which  may  be  present 
in  the  secondary  or  tertiary  period.  The  mucous  surfaces,  as  well  as 
the  integument  proper,  are  affected.  Not  infrequently  the  pnpuho  are 
preceded  or  accompanied  by  macuhe.  The  papuljB  assume  various 
shapes,  some  being  small  and  pointed,  others  broader  at  the  base  and 
flat  on  top,  in  shape  like  a  truncated  cone.  Upon  mucous  surfaces  the 
papular  character  of  the  erupti(m  may  be  observed  if  seen  early  in  its 
appearance ;  but,  on  account  of  the  moisture  present,  the  papules  soon 
disa])pear,  leaving  patches  which  may  be  elevated  or  depressed.  Mucous 
patvhe.s,  when  recent,  are  red  in  color,  but  later  become  covered  with  a 
grayish  film. 

The  papular  syphilide,  which  occurs  near  the  junction  of  the  skin 
and  mucous  surfaces,  or  in  the  deep  folds,  as  these  below  the  mammary 

glands  in  women,  and  the  thighs 
and  gluteal  regions  in  fleshy  in- 
dividuals of  either  sex,  not  in- 
frequently, as  a  result  of  un- 
cleanliness  and  irritation,  be- 
comes developed  into  papillary 
or  warty  growths  known  as  con- 
dylomata (Fig.  652). 
<^  W  "^^^^  eruption  comes  out   in 

some  cases  over  the  entire  body ; 
in  others   the  face  is  exempt. 
„     ^.,    ,.     , ..  ,  ,      .     f  ,       ,  The  palms  of  the  hands  and  the 

Fig.  6o*2. — \  e^etntini^  condvlomiitft  ot  the  vulva.  ^ 

(Atter  Uuraitead  and  JuUien.)  soles  of  the  fcet  ars  not  infre- 

quently invaded.  At  times  the 
trunk  is  chiefly  occupied  ;  the  face,  hands,  and  feet  escaping.  Tlie  mar- 
gins of  the  papulae  are  well  defined,  varying  in  size  as  did  the  macuhe, 
and  also  in  color.     In  the  main  they  are  darker,  and  the  pigmentation 


SYPHILIS.  649 

is  more  marked.  The  eruption  disappears  by  absorption  of  the  cells 
which  liave  inliltrated  the  papillfc  and  corium,  and  this  may  occur  with 
or  without  desiccation  or  scaling.  The  scaling  syphiUde,  or  so-called 
psoriasis  syjyliHitica,  is  at  times  with  difficulty  differentiated  from  true 
psoriasis,  especially  when  the  venereal  inoculation  is  denied. 

The  vesicular  syphilide  is  peculiar  to  the  second  stage,  and  is  seldom 
observed.  The  vesicles,  like  the  papules,  may  be  small,  pointed,  and 
gathered  in  clusters,  as  in  herpes  ;  or  larger,  like  the  vesicles  of  chicken- 
pox,  and  scattered  at  varying  intervals  over  the  entire  body.  Commenc- 
ing as  vesicles,  they  may  become  pustules,  which,  as  evaporation  occurs, 
are  covered  with  small  crusts  or  scabs. 

The  pustular  syjAilide  may  be  met  with  on  all  parts  of  the  body, 
and  may  originate  as  a  pustule,  or,  as  stated  above,  become  i^ustular 
from  a  vesicular  or  papular  origin.  This  variety  of  cutaneous  lesion, 
wiiile  most  common  in  secondary,  is  not  infrequently  seen  in  tertiary 
syphilis.  The  smaller-sized,  more  superficial  pustules,  belong  naturally 
to  the  earlier  period  ;  those  with  wide  bases  and  more  extensive  tissue- 
destruction,  to  the  later  manifestations. 

The  pustular  syphilide  originates  around  and  in  the  hair-follicles. 
In  mild  cases,  and  when  of  small  size,  the  limit  of  infiltration  and  pus- 
tulation  is  immediately  around  the  follicle.  In  other  cases  the  infiltra- 
tion is  wider,  and  the  destructive  process  more  extensive. 

Scabbing,  with  underlying  ulceration  varying  in  extent,  is  the  com- 
mon history  of  all  pustular  syphilides,  although  extensive  molecular 
death  of  tissue  is  less  apt  to  occur  in  the  secondary  than  in  the  tertiary 
stage.  The  color  of  the  crusts  varies  from  black  to  a  brownish-copper 
color.  If  the  scab  is  removed,  the  walls  of  the  ulcer  will  be  seen  to  be 
precipitate  and  curvilinear  in  outline,  while  the  floor  is  covered  with  a 
varying  amount  of  fluid  and  detritus. 

The  tubercular  syphilide  is  so  rarely  a  lesion  of  secondary  syphilis 
that  it  will  be  described  with  the  sjinptoms  of  the  thii-d  stage  of  this 
disease. 

It  is  exceedingly  rare  to  observe  all  of  the  foregoing  syphilides  in 
any  single  individual.  The  macular  and  papular  eruptions  are  fre- 
quently met  with  together,  while  the  pustular  syphilide  usually  exists 
alone. 

Alopecia  occurs  in  a  varying  degree  in  most  cases  of  syphilis. 
Though  noticed  chiefly  in  the  scalp  and  beard,  all  the  hairy  portions 
of  the  body  are  involved.  Except  in  the  case  of  the  pustular  syphilide, 
the  follicles  are  rarely  destroyed,  so  that,  as  the  violence  of  the  attack  is 
diminished,  the  hairs  are  reproduced.  Alopecia,  from  general  sebor- 
rha?a,  is  one  of  the  later  manifestations  of  syphilis. 

Fever. — Elevations  of  temperature  occur  in  the  second  stage  of  syphi- 
lis in  a  large  proportion  of  cases.  In  mild  attacks  it  may  not  be  ob- 
served, but  in  many  instances  the  thermometer  will  register  from  one  to 
two  or  three  degrees  above  the  normal.  The  febrile  movement  usually 
begins  when  the  virus  has  passed  through  the  first  network  of  lymphat- 
ics and  is  being  disseminated  throughout  the  tissues.     It  may  precede 


650  A   TEXT-BOOK  ON  SURGERY. 

the  eruption  or  occur  with  it,  and,  as  a  rule,  continues  after  the  eruption 
fades  away. 

Headache^  usually  referred  to  the  frontal  region,  at  times  to  the  ver- 
tex or  base,  occurs  during  the  period  of  fever,  and  is  generally  propor- 
tionate to  the  intensity  of  the  febrile  niovenient. 

Arteritis,  lymplaDigitis,  and  general  adenitis  occur  in  the  second 
stage,  and,  in  neglected  cases,  continue  until  the  third  stage.  Iritis  is 
not  uncommon  in  secondary  syphilis.  It  is  nsunlly  unilateral,  and  may 
be  recognized  by  immobility  of  the  iris,  photophobia,  and  by  the  injec- 
tion of  the  membrane. 

Pathological  changes  in  the  bones  do  not  occur,  as  a  rule,  in  the  ear- 
lier stages  of  syphilis.  Pain,  usually  mild  in  character,  is  present  in 
some  cases  in  the  second  stage,  but  lesions  of  the  osseous  structures  be- 
long especially  to  the  last  stage  of  this  disease. 

T/iird  St(ff/r. — The  lesions  of  tertiarif  syphilis  manifest  themselves 
not  earlier  than  the  second  year  of  the  disease.  Once  present  they 
may  continue  for  a  while,  and  disappear,  to  return  at  varying  intervals 
during  the  life  of  the  individual.  No  tissue  or  organ  is  exempt  from 
the  grave  pathological  chauges  induced  by  the  syi)hilitic  virus  in  this 
stage. 

Skiv. — Externally,  the  changes  in  the  skin  are  chiefly  those  of  ulcera- 
tion. Nodules,  resulting  from  cell-proliferation  and  accumulation  in  the 
deeper  layers  of  the  skin,  and  at  times  in  the  subcutaneous  tissues  {gum- 
inata),  appear,  and  after  existing  for  a  variable  period  of  time  may,  by 
interference  with  the  nutrition  of  the  part,  lead  to  molecular  death  of 
the  adjacent  tissues,  or,  failing  in  this,  undergo  fatty  metamorphosis  and 
absorption.  If  an  ulcer  exists,  it  has  the  usual  shape  of  the  syi)hilitic 
sore — round,  oval,  or  curvilinear,  with  regular  edges,  not  ragged  or  in- 
dented. When  granular  degeneration  of  the  new  tissue  occurs,  the  skin 
Immediately  over  the  tubercle  has  a  stretched  or  glazed  appearance,  and 
is  slightly  discolored. 

A  not  infrequent  pustular  cutaneous  lesion  of  the  third  stage  of 
syphilis  is  known  as  rt(j)ia  Sf/p7/ititica.  In  very  rare  instances  a  pus- 
tular syphilide,  similar  in  appearance  and  with  difficulty  differentiated 
from  rupia,  occurs  as  a  secondary  lesion.  I  presented  one  such  case, 
with  an  unmistakable  history  of  acute  syphilis,  to  the  New  York  Patho- 
logical Society  in  1884.  The  pustules  in  rupia  syphilitica  are  usually 
circular  or  oval  in  shape,  appear  as  slight  elevations  or  blebs,  which  soon 
break  oi^en.  The  sero-purulent  contents  ooze  out ;  evaporation  and  scab- 
bing occur ;  the  crusts,  by  reason  of  the  new  deposit  underneath,  are 
gradually  lifted,  and  give  to  the  scab  a  laminated,  rough  apjiearance, 
not  unlike  that  of  an  oyster-shell.  The  crusts  have  a  dark-brown  or 
slightly  greenish  hue. 

When  the  late  cutaneous  lesions  of  syphilis  attack  the  fingers,  the  nail 
or  matrix  is  affected  (paronychia),  causing  a  roughened  condition  of  the 
nail  and  a  swollen  matrix,  leading  frequently  to  temporary,  and  occa- 
sionally to  permanent,  loss  of  the  organ.  In  like  manner,  j)ermanent 
alopecia  may  occur  from  destruction  of  the  hair-f oUicles. 


SYPHILIS.  651 

Nervous  System — Brain. — Paralysis  is  one  of  the  more  frequent  le- 
sions of  tertiary  syphilis,  and  may  result  from  one  of  several  causes, 
namely — pressure  of  a  gumma  developed  Avithin  the  brain-substance 
proper  or  upon  the  investments ;  pressure  from  syphilitic  exostosis  of 
the  skull ;  destruction  of  brain-cells  by  connective-tissue  hyperplasia  in 
the  neuroglia,  with  consequent  cicatrization  and  conti-action ;  more  or 
less  complete  occlusion  of  the  arteries  {endarteritis  obliterans). 

Hemiplegia,  partial  or  complete,  is  the  rule.  Occasionally  the  center 
of  language  is  alone  aifected.  Dementia  may  ensue  as  a  result  of  soft- 
ening or  pressure,  and  epilepsy  may  be  classed  among  the  late  manifesta- 
tions of  this  disease. 

Chronic  meningitis  is  an  occasional  symptom  of  late  syphilis.  It  is 
accompanied  by  headache,  dull  and  persisting  in  character,  impainnent 
of  intellect,  interference  with  the  functions  of  one  or  more  of  the  cranial 
nerves  by  extension  of  the  morbid  process,  resulting  at  times  in  ptosis, 
strabismus,  or  impairment  of  vision,  hearing,  taste,  smell,  etc.  The  more 
serious  cases  progress  gradually  to  coma  and  death.  There  is  in  all  an 
elevation  of  temperature,  loss  or  impairment  of  appetite,  and  derangement 
of  the  entire  digestive  apparatus. 

The  spinal  cord  and  its  membranes,  though  less  frequently  attacked 
than  the  brain,  may  be  involved  as  a  resiilt  of  similar  pathological  con- 
ditions. Paraplegia  more  or  less  comi)lete  ensues,  involving  at  times 
the  bladder  and  rectum.  In  milder  cases  co-ordination  is  disturbed,  with 
little  or  no  loss  of  muscular  power.  Pain  may  be  i^resent,  referred  to 
the  back  at  or  near  the  seat  of  the  lesion,  or  along  the  distribution  of  the 
sensory  nerves,  or  anesthesia  may  occur. 

One  or  more  of  the  nerves,  sensory  or  motor,  may  in  like  manner  be 
affected  as  a  result  of  the  development  of  gummata,  or  connective-tissue 
changes  in  the  neurilemma,  or  the  pressure  of  exostoses  or  other  neo- 
plasms. 

Bones. — Periostitis  and  ostitis,  especially  in  those  portions  of  the 
skeleton  most  exposed  to  sudden  changes  in  temi^erature  and  to  direct 
violence,  are  among  the  more  frequent  lesions  of  tertiary  syphilis.  The 
bones  of  the  skull,  the  spine  of  the  tibia,  and  the  clavicle,  are  more  often 
involved.  The  swelling  caused  by  the  inflammatory  exudation  may  be 
readily  appreciated  by  palpation,  and  pain  or  tenderness  is  present  on 
direct  pressure.  The  tumefaction  results  from  the  formation  of  new 
bone  (exostosis),  which  in  some  instances  persists  indelinitely. 

Gummata  are  developed  upon  or  beneath  the  periosteum,  forming 
soft,  semi-fluctuating  swellings,  usually  cu'cular  in  shape,  and  from  a 
half-inch  to  an  inch  or  two  in  diameter.  These  tumors  or  nodes,  while 
not  very  painful  under  ordinary  pressure,  are  the  seat  of  exacerba- 
tions of  pain  which  are  usually  experienced  at  night.  They  frequent- 
ly break  down  in  a  in'ocess  of  ulceration  which  involves  the  underly- 
ing bfme. 

AVhen  the  inflammatory  process  is  violent,  extensive  necrosis  may 
occur.  A  peculiar  type  of  ostitis  in  the  later  manifestations  of  syphilis 
is  that  known  as  osteitis  rarefaciens,  in  which  there  is  no  suppuration  or 


652  A  TEXT-BOOK   ON   SURGERY. 

exfoliation,   a   portion  of    the   bone-substance  nndergoing  absoqition, 
giving  to  tlie  part  involved  a  porous  or  worm-eaten  appearance. 

Hypertrophy  of  the  bones,  even  to  a  remarkable  degree,  is  not  nn- 
common,  and  may  be  due  to  the  development  of  compact  substance 
beneath  the  periosteum,  or  the  entire  cancellous  portion  may  be  replaced 
by  this  eburnated  tissue.  On  the  other  hand,  the  hypertro])hy  is  in 
some  cases  entirely  cancellous  in  character,  the  bone  taking  on  two  or 
three  times  its  natural  thickness. 

Johiffi. — The  patlidlogiciil  changes  in  bone  may  also  be  accnnipnuicd 
by  like  changes  iu  the  articuhitions. 

Synovitis,  with  thickening  of  the  membrane  and  surrounding  ca])- 
sule,  is  present,  accompanied  by  impairment  of  motion  nnd  [niin  of  a  dull 
character.  In  severer  cases,  the  cartilages  and  bones  become  involved, 
leading  to  osteo-arthritis  and  destruction  of  the  joint. 

Ilea  ft  and  Vessels. — Fatty  degeneration  of  the  heart-muscle,  follow- 
ing syphilitic  mj'ocarditis,  and  the  formation  of  guumiata  upon  the  peri- 
cai-dium  or  within  the  muscular  walls,  are  the  chief  lesions  of  this  organ 
in  the  tertiary  period.  The  pericardium  may  also  be  affected,  and  in 
like  manner  the  endocardium,  which  may  undergo  atheromatous  degen- 
eration or  give  rise  to  vegetations.  Of  the  vessels,  the  capillaries  always 
affected  in  the  first  and  second  stages,  are  not  so  seriously  involved  in 
the  last  stage  as  the  arteries.  The  veins  are  rarely  affected.  Arteritis, 
especially  the  variety  known  as  endarteritis  obliterans,  is  one  of  the 
most  common  and  grave  lesions  of  chroiuc  syi)hilis.  While  the  larger 
trunks  are  involved,  the  more  characteristic  changes  occur  in  the  teruiinal 
arteries  and  arterioles.     The  cerebral  vessels  are  especially  susceptil)lt'. 

Lymphatics. — Gummatous  deposits  occasionally  take  place  in  the 
lympliatic  glands  in  tertiary  syphilis.  The  superficial  set  may  break 
down  and  discharge  their  contents.  The  deei)  glands  undergo  granular 
degeneration  with  absocption,  or  the  gummatous  material  undergoes  the 
caseous  or  calcareous  degeneration. 

Respiratory  System — JYose. — The  mucous  membrane  may  be  thick- 
ened, or  may  be  more  or  less  destroyed  by  ulceration.  The  cartila.ge 
and  bony  framework  of  this  organ  are  very  often  destroyed. 

Larynx. — The  mucous  membrane  of  the  larynx  may  also  be  thick- 
ened, or  the  seat  of  ulcers  or  vegetations.  Chondritis  and  perichondritis 
are  not  infrequent ;  and,  as  a  result  of  the  chronic  inflammation,  stricture 
and  stenosis,  more  or  less  complete,  may  occur  from  cicatricial  contrac- 
tion. It  may  also  be  the  seat  of  gummata.  The  trachea  and  bronchi  are 
subject  to  similar  lesions,  inducing  strictui-e. 

In  the  lungs  the  principal  lesions  are — (1)  chronic  interstitial  or  fibrous 
pneumonia ;  (2)  more  or  less  widely  disseminated  gummatous  deposits, 
usually  in  the  lower  portions  of  these  organs. 

Digestive  System — Modth. — Superficial  ulcers  of  the  walls  of  the 
buccal  cavity  are  not  infrequent ;  deep,  destructive  ulcers  are  rare.  This 
can  not,  however,  be  said  with  truth  concerning  the  palate,  where,  as  a 
result  of  gummatous  deposits  or  general  infiltration,  the  most  rapid  and 
irreparable  destruction  of  tissue  may  occur.     The  curtain  of  the  soft 


SYPHILIS.  653 

palate  is  frequently  destroyed,  the  bony  septum  between  the  mouth  and 
nose  is  perforated,  while  in  extreme  cases  the  pillars  of  the  fauces  and 
the  pharynx  are  involved.  Other  lesions  of  the  pharynx  do  not  differ 
from  those  of  the  buccal  cavity. 

Tongxie. — Gummatous  deposits  may  occur  in  any  portion  of  this 
organ,  causing  local  or  general  tumefaction.  Whether  supei'ficial  or 
deep,  they  tend  to  break  down,  giving  rise  to  ulcers  varying  in  size  and 
depth.  The  other  principal  lesion  of  the  tongue  in  the  tertiary  period  is 
more  or  less  widely  diffused  connective-tissue  hyperplasia,  giving  rise  to 
a  varying  degree  of  enlargement.  As  the  new-formed  tissue  contracts  it 
gives  to  the  organ  a  lobulated  appearance,  the  boundaries  of  the  lobules 
being  well-marked  lissures  in  the  line  of  the  contracting  bands. 

(E>iopliagus. — Partial  or  complete  occlusion  of  the  oesophagus  may 
occur  from — (1)  connective-tissue  hyperplasia  in  its  walls,  or  the  contrac- 
tion following  ulcer  (organic  stricture) ;  (2)  the  mechanical  obstruction 
from  gummatous  deposits  in  the  walls  or  in  the  immediate  neighborhood 
of  the  oesophagus ;  (3)  pressure  from  exostoses,  aneurisms,  enlarged 
glands,  etc.  Syphilitic  ulcers  of  the  stomach  and  alimentary  canal  have 
been  observed,  though  rarely.  Gummata  form  here,  however,  with  a 
certain  degree  of  frequency,  and  stricture  of  the  pylorus,  and  of  the  in- 
testinal canal  above  the  rectum,  is  known  to  occur  in  a  certain  propor- 
tion of  cases.  The  rectum  is  especially  liable  to  become  seriously  in- 
volved in  the  late  manifestations  of  syphilis.  Here,  as  elsewhere,  strict- 
ure may  result  from  iilirillation  and  contraction  of  the  inflammatory  tissue 
with  which  the  walls  of  this  organ  and  the  jieri-rectal  tissues  may  be- 
come infilti'ated.  Again,  ulcers  originating  within  the  gut,  or  extending 
from  a  like  inflamm:itory  process  about  the  anus  and  the  external  tissues, 
or  the  presence  of  gummatous  material,  may  all  induce  more  or  less 
serious  contraction  of  the  lumen  of  the  rectum.  Of  the  solid  abdominal 
viscera,  the  liver  is  most  seriously  affected.  The  pathological  changes 
are — (1)  connective-tissue  hyperplasia  or  chronic  interstitial  hepatitis  or 
sypliilitic  cirrhosis,  which  may  be  general  or  local ;  (2)  gummata  in  any 
portion  of  the  organ  ;  (3)  waxy  degeneration  from  long-continued  general 
sepsis. 

The  spleen,  may  undergo  similar  changes.  Slight  enlargement  may 
occur  from  the  excess  of  white  corpuscles  (leucocytha^mia),  which  is  the 
rule  in  this  disease. 

The  pancreas  is  rarely  affected. 

Genito-urinary  System. — Amyloid  degeneration  of  the  kidneys  oc- 
curs as  a  result  of  the  long-continued  sepsis  of  sypliilis,  as  with  other 
chronic  forms  of  blood-poisoning.  In  like  manner,  under  conditions  fa- 
vorable to  connective-tissue  hyperplasia,  the  fibrous  stroma  of  this  organ 
becomes  thickened,  with  consequent  atrophy  of  the  excretory  or  glandu- 
lar elements  (chronic  interstitial  nephritis). 

Gummata.  of  the  kidney  is  not  as  common  as  in  other  viscera. 

Orchitis,  although  occurring  while  some  of  the  secondary  symptoms 
may  be  present,  is  essentially  a  late  manifestation  of  this  disease.  It  is 
important  to  recognize  it,  since  several  varieties  of  sarcocele  require  im- 


654  A  TEXT-BOOK  ON   SURGERY. 

mediate  surgical  interference.  Syphilitic  orcliitis  should  be  suspected 
in  all  cases  of  tumor  of  this  organ  in  which  there  is  a  history  of  specitic 
infection.  In  syphilis,  the  enhii'genient  is  apt  to  occur  in  both  orgiins 
about  the  same  time.  The  growth  is  smooth  and  sphericnl,  and  when 
lifted  conveys  the  sense  of  unusual  weight.  It  is  not  painful,  excepting 
always  the  sense  of  dragging,  wliich  is  ;it  times  annoying.  Slight  hydro- 
cele not  infrequently  accompanies  this  form  of  orchitis. 

The  testicles  are  not  exempted  from  gummatous  deposits.  In  rare  in- 
stances these  break  down,  causing  more  or  less  destruction  of  the  sub- 
stan(^e  of  these  oi'gans.  The  penis  is  occasionally  the  seat  of  syphilitic 
iniiltration  in  the  later  stages  of  this  affection. 

The  Eye. — Syphilitic  iritis  lias  been  given  as  occurring  in  the  second 
stage  of  this  disease.  It  may  also  occur  as  a  later  manifestation.  In- 
tlammation  of  the  sclera,  choroid  and  ciliary  bodies,  lens  and  capsule, 
retina,  and  (though  rarely)  of  the  optic  nerve,  are  of  varying  fi'equency 
in  the  tertiary  period.  Lesions  of  the  muscles  may  be  due  to  connective- 
tissue  new  formations  between  the  fasciculi,  resulting  in  granular  degen- 
eration of  the  muscle-substance  and  contraction  of  the  new  tissue.  It 
nay  occur  in  the  second  as  well  as  the  third  stage  of  this  disease.  These 
contractions,  if  not  relieved,  may  result  in  anchylosis  of  the  joint  in  im- 
mediate anatomical  relation  to  the  muscles  involved.  Grummata  are  not 
of  frequent  occurrence.  They  terminate  by  suppuration  or  by  absorp- 
tion,    lutiammatiou  in  the  tendons  and  their  sheaths  may  also  occur. 

Fingers  and  Toes. — The  lingers  and 
toes,  during  the  tertiary  period  of  syph- 
ilis, in  a  certain  proportion  of  cases  be- 
come the  seat  of  gummatous  deposits, 
the  skin  and  subcutaneous  tissues  may 
be  infiltrated,  or  the  bones  and  cartilages 
may  be  involved.  When  the  infiltration 
is  confined  to  the  soft  parts,  the  entire 

Fio.  f>53. — Syphilitic  dactylitis.  .,,  „     ii    „    ,„  1    ,  .,„„i„  ^.. 

(After  Bergii  and  Bumstiad.)  orgau  Will  appear  swolleu  and  inirple  or 

reddish  in  color.  When  the  bone  is  the 
seat  of  the  deposit,  it  may  be  limited  to  a  single  phalanx  (Fig.  6.1H)  or 
invade  all  the  bones  of  the  finger.  The  process  terminates  in  ulcer, 
necrosis,  or  granular  degeneration  of  the  cells  of  the  new  tissue,  and 
absorpticm. 

Pathol ogy  of  Si/pJiilis. — The  chief  feature  in  the  pathology  of  syphi- 
lis in  all  of  its  stages  is  the  proliferation  of  an  embrycmic  tissue,  usually 
of  a  type  so  low  that  it  is  not  capable  of  organization  into  a  definite 
tissue.  From  the  initial  lesion  and  the  primary  lymphangitis  and  ade- 
nitis to  the  final  lesions  of  the  viscera,  this  cell-proliferation  continues, 
and  the  different  effects  vdtnessed  in  different  individuals,  or  in  the  same 
individual,  in  the  various  stages  of  the  disease,  depend  chiefly  upon  the 
degree  of  impairment  in  the  nutrition  of  the  tissues.  The  cell-accumu- 
lation in  and  around  the  capillary  loops  of  the  cutaneous  papilhe,  which 
produce  a  macular  or  papular  syi)hilide  in  one  individual  whose  tissues 
are  in  a  condition  of  perfect  nutriticm,  will  i^roduce  a  squamous  or  vesic- 


PATHOLOGY  OF  SYPHILIS.  655 

ular  eruption  in  another,  or  a  pustular  syphilide  in  a  third  who  has  the 
unfortunate  inheritance  of  a  gouty,  scrofulous,  or  tubercular  dyscrasia. 
Or  a  papular  lesion  of  tlie  first  stage,  in  which  the  process  of  nutrition 
in  the  tissues  is  normal,  may  be  replaced  by  a  rupia  in  the  tertiary  pe- 
riod when  assimilation  is  less  perfect. 

If  the  initial  lesion  of  syphilis  is  excised  and  examined  witli  the  mi- 
croscope, the  following  conditions  will  be  observed  :  The  epidermis  in 
the  inmiediate  vicinity  of  the  ulcer  is  more  or  less  completely  destroyed. 
The  membrane  which  covers  the  floor  of  the  ulcer  is  composed  of  i)us- 
cells,  fragments  of  epidermal  cells,  cells  of  the  Malpighian  layer,  and 
fragments  of  connective-tissue  and  other  detritus.  These  elements  vary 
in  proportion  as  the  process  of  necrobiosis  is  limited  or  extensive.  In 
the  deeper  i^ortions  of  the  Malpighian  layer,  and  in  and  around  the  pa- 
pillae where  these  layers  are  not  wholly  destroyed,  and  in  the  connective- 
tissue  layer  of  the  skin,  there  is  a  general  infiltration  with  the  embry- 
onic cells  of  the  syphilitic  process. 

The  arterioles,  veins,  and  capillaries  are  more  or  less  completely  oc- 
cluded. The  cell-proliferation  is  especially  marked  in  the  arterioles,  the 
adventitia  and  intima  are  thickened,  the  thickening  being  more  marked 
in  the  latter,  while  the  lumen  of  the  vessel  is  more  or  less  encroached 
upon  by  the  new-formed  tissue.  The  venules  undergo  analogous  changes. 
The  walls  of  the  lymph-channels  are  thickened,  and  many  of  these  ves- 
sels are  crowded  with  cells.  The  iniiltration  is,  however,  limited  to  the 
immediate  borders  of  the  ulcer,  and  the  line  between  this  and  the  unin- 
vaded  tissue  is  sharply  defined.  As  the  mass  of  cells  gradually  obstruct 
the  vessels,  the  nutrition  of  the  new  tissue  is  interfered  with,  and  it  either 
undergoes  granular  metamorphosis  or  breaks  down  more  rapidly  as  a 
slough.  The  absence  of  pain  in  the  chancre  is  also  explained  liy  the 
gradual  pressure  upon  the  terminal  nerves  and  the  comparative  dryness 
of  the  typical  sore  to  the  arterial  occlusion. 

The  lympTiatics  immediately  around  the  ulcer,  and  those  leading  from 
it  to  the  nearest  glands,  are  more  or  less  filled  with  the  new  cells,  and 
their  walls  appear  tliicker  than  normal. 

The  changes  which  occur  in  the  glands  in  the  eai'lier  stages  of  syphi- 
lis consist  in  a  hyperplasia  of  the  connective-tissue  cells  of  the  stroma 
and  thickening  of  the  fibrous  framework,  together  with  an  increase  in 
the  cell-elements  of  the  gland-substance  proper. 

The  cutaneous  lesions  of  secondary  syphilis  result  from  the  more  or 
less  complete  obstruction  of  the  caj)illary  loops  of  the  papillae  by  the 
cells  of  this  indifferent  tissue.  The  walls  of  the  capillaries  undergo  de- 
generation ;  the  coloring-matter  of  the  blood  escapes,  causing  the  pecul- 
iar staining  of  the  syphilides.  In  the  macular  syphilide  the  abnormal 
cell-accumulation  is  less  than  in  the  papular  eruption.  The  changes 
which  occur  in  mucous  patches  differ  very  slightly  from  those  described 
in  the  cutaneous  lesions.  The  ejndermis  soon  breaks  down ;  the  Malpig- 
hian layer  and  papillee  are  infiltrated  with  the  ceU-elements  ;  while  the 
capillaries,  arterioles,  and  lymiihatic  vessels  undergo  changes  almost 
identical  with  those  described  in  the  initial  lesion. 


656  A  TEXT-BOOK  ON  SURGERY. 

In  the  later  or  tertiary  lesions  of  the  skin  in  syjjliilis,  tlic  infiltration 
is  deepei".  Cutuneons  gummata  consist  of  aggregations  of  the  cell-ele- 
ments heretofore  described,  whicli  are  crowded  into  the  snlxnitaneous 
areolar  tissue,  ijito  tlic  connective  tissue  of  the  true  skin,  in  tlie  walls  of 
and  just  outside  the  vessels,  while  the  endothelia  of  these  vessels  under- 
go prolift>rntion  and  aid  in  thiMr  occlusion.  Ulceration  ensues  from  the 
rapid  arrest  of  nutrition,  and  tlie  process  of  necrobiosis  is  aided  by  the 
depi'essed  condition  of  the  tissues  which  usually  exists  in  the  tertiary 
stage  of  syphilis.  The  tertiary  lesions  of  the  mucous  surfaces  are  analo- 
gous to  those  of  the  integument. 

The  pathology  of  visceral  syphilis  pi'esents  two  distinct  morbid  pro- 
cesses :  (1)  the  hyperplasia  of  the  connective-tissue  stroma  of  the  organs 
(cirrhosis) ;  and  {2)  the  aggregation  of  the  syphilitic  embryonic  cells 
(gumma).  The  character  of  these  changes  in  the  different  organs  has 
been  given. 

Diagnosis. — In  a  typical  case  of  acquired  syphilis  a  diagnosis  may 
be  made  upon  the  following  symptoms :  1,  an  ulcer  in  appearance  and 
behavior  like  that  described  as  belonging  to  the  initial  lesion  of  this 
disease,  the  sore  occurring  not  less  than  ten  days,  and  usually  about  the 
twentieth  day,  after  an  exposure  ;  2,  induration  and  enlargement  of  the 
nearest  lympliatic  glands  occurring  in  from  eight  to  fourteen  days  after 
the  appearance  of  the  ulcer  ;  3,  after  from  two  to  four  weeks  of  seeming 
arrest  of  the  infection,  the  development  of  headache,  pain  in  the  back, 
slight  febrile  movement,  Avlth  an  eruption  (sixth  to  seventh  week  after 
the  appearance  of  tlie  sore)  over  all  or  a  portion  of  the  body,  accom- 
panied with  an  unusual  sense  of  dryness  or  soreness  of  the  mouth,  phar- 
ynx, or  fauces  ;  4,  following  or  occiirring  with  these  symptoms,  general 
adenitis. 

In  the  majority  of  cases,  excluding  even  those  in  which  the  sore  is 
concealed,  as  in  the  urethra,  etc.,  little  value  can  be  placed  xipon  the 
appearance  of  the  ulc:^r  at  the  point  of  infection.  The  classi(!al  "initial 
lesion"  of  syphdis,  with  its  well-defined  margin  of  induration,  feeling 
like  a  "si)lit  pea"  or  piece  of  cartilage  when  grasped  between  the  thumb 
and  finger;  the  absence  of  pain  and  peripheral  iiiilammation  ;  the  pe- 
cidiar  "scooped-out"  concavity  of  the  sore,  the  surface  of  which  is  cov- 
ei'ed  with  a  scanty,  serous  transudation,  is  so  frequently  absent  in  cases 
in  which  the  later  and  unmistakable  signs  of  this  disease  are  developed, 
that  it  alone  can  not  be  relied  upon  in  arriving  at  a  diagnosis.  As  stated 
heretofore,  the  syphilitic  virus  may  be  lodged  in  and  absorbed  from  a 
phagedenic  ulcer  in  which  not  a  single  feature  of  the  specific  sore  is 
present.  The  same  is  true  of  the  herpetic  idcei',  or  that  resulting  from 
traumatism  or  the  inoculation  of  any  form  of  virus.  All  of  these  ulcers 
are  grouped  under  the  heading  of  "mixed  sores." 

Induration  of  the  glands  is  more  reliable  in  a  diagnostic  sense.  AVhen 
the  typical  initial  lesion  is  present,  the  ensuing  adenitis  is  also  typical. 
In  the  inguinal  region  one  gland  of  the  group  after  another  is  enlarged 
and  becomes  indurated.  The  process  is  slow  and  deliberate.  There  is 
no  periadenitis,  the  glands  do  not  adhere  to  each  other  and  the  interven- 


DIAGNOSIS  OF  SYPHILIS.  657 

ing  tissues,  nor  to  the  integument.  Each  body  may  be  distinctly  made 
out  by  palpation  and  moved  beneath  the  skin  independently.  There  is 
no  tenderness,  and  the  gland  is  leathery  to  the  touch.  Even  when  the 
sore  is  mixed,  if  the  i)hagedenic  or  intlammatory  process  is  not  severe, 
the  adenitis  is  more  apt  to  be  specific  than  intiammatory,  and  wUl  pos- 
sess the  features  of  syphilitic  bubo  in  a  sufficient  degree  to  admit  of 
recognition.  When  the  specific  infection  is  complicated  with  a  typical 
phagedenic  ulcer  or  gonoirhoea,  the  resulting  bubo  does  not  possess  a 
single  appreciable  feature  of  syphilitic  adenitis. 

The  eruption  of  syphUis  is,  of  all  the  symptoms  of  this  disease,  the 
most  reliable.  When  the  sore  is  mixed,  and  the  chai-acter  of  the  ade- 
nitis doubtful,  the  early  cutaneous  and  mucous  lesions  are,  in  the  vast 
majority  of  cases,  appreciable  and  unmistakable.  Headache,  rise  in  tem- 
perature, pains  in  the  back,  etc.,  are  confirmatory  symptoms,  but  inde- 
pendently of  no  value.  The  same  may  be  said  of  dryness  or  soreness  of 
the  mouth,  pharynx,  and  fauces.  Lastly,  general  adenitis,  which  occurs 
in  a  varying  degree  in  all  cases  of  syphilis  in  which  mercurialization  has 
not  been  effected  at  a  very  early  date,  is  a  strong  confirmatory  symptom, 
and  of  great  value  in  diagnosis  if  all  the  other  lesions  have  escaped  ob- 
servation. The  greatest  importance  is  attached  to  induration  of  the 
epitrochlear,  and  to  the  occipital  and  post-mastoid  glands.  The  former 
can  scarcely  be  recognized  in  their  normal  state.  In  general  adenitis  a 
single  body,  feeling  like  a  small  bean  in  shape,  may  be  recognized  at  the 
inner  aspect  of  the  arm  just  above  the  elbow,  where  it  lies  superficial, 
and  internal  to  the  basilic  vein.  When  any  inflammatory  process  exists 
in  the  member  beyond  the  elljow,  the  enlarged  gland  possesses  no  spe- 
cific diagnostic  value.  In  like  manner  lesions  of  the  scalp,  face,  or 
mouth  may  cause  enlargement  of  the  occipital  or  mastoid  IjTnphatic 
glands. 

A  diagnosis  of  syphilis  in  the  tertiary  period  must  depend  upon  a 
careful  study  of  the  history  of  the  case  and  the  presence  of  one  or  more 
of  the  lesions  which  belong  to  this  stage,  and  which  have  been  fully  de- 
scribed. 

Prognosis. — A  favoi'able  prognosis  in  syphilis  will  depend  upon — 1, 
the  physical  condition  of  the  individual  affected  at  the  time  of  inocula- 
tion ;  2,  the  recognition  of  the  disease  within  the  first  two  or  three 
months  after  the  appearance  of  the  ulcer ;  3,  the  faithful  and  energetic 
co-operation  of  the  physician  and  patient  in  carrying  out  the  measures 
to  be  given. 

That  syphilis  is  a  curable  disease  there  can  be  no  doubt.  Under 
favorable  conditions  the  symi>toms  disappear,  leaving  little  or  no  trace 
of  the  infection.  In  common  with  ail  diseases,  its  severe  or  fatal  results 
are  seen  in  patients  with  an  inherited  or  acquired  dyscrasia,  and  in  those 
whose  nutrition  is  seriously  impaired.  Even  in  the  worst  class  of  cases 
the  prognosis  is  not  wholly  unfavorable  if  proper  treatment  is  instituted 
and  maintained. 

The  recognition  of  the  disease  and  the  institution  of  treatment  at  the 
time  of,  or  immediately  after,  the  appearance  of  the  eruption,  is  impor- 

42 


658  A  TEXT-BOOK  ON  SURGERY. 

tant  in  secnrins  a  favorable  result  ;  foi-,  if  this  is  done,  the  violence  of 
the  infection  may  be  modified  and  the  deeper  lesions  rendered  less  severe. 
Treatment. — The  treatment  of  syiihilis  is  divided  into — 1,  measures 
vvhicdi  tend  to  destroy  the  potency  of  the  virus  and  aid  in  absorption  of 
the  inflammatory  products  of  this  disease ;  and,  2,  those  which  tend  to 
improve  the  nutrition  of  tlie  tissues.  Both  are  essential  to  the  successful 
management  of  this  formidable  affection. 

To  the  former  belong  the  preparations  of  mercury  and  iodine  in  com- 
bination with  ])otassium  ;  to  the  latter  tonics,  the  careful  regidation  of 
the  habits  of  living,  nutritious  diet,  and  healthful  and  moderate  exercise. 

Nothing  is  more  satisfactorily  demonstrated  in  scientific  medicine 
than  the  power  of  mercury  to  neutralize  and  destroy  the  virus  of  syphi- 
lis. Its  administration  should  usually  l)egin  with  the  i)ositive  recog- 
nition of  the  disease  at  the  appearance  of  the  eruption  (usually  about  the 
sixth  or  ninth  week).  It  is  always  advisable  to  wait  until  tlie  diagnosis 
is  assured,  rather  than  to  begin  treatment  with  the  recognition  of  the 
sore  or  bubo.  It  has  been  stated  that  these  symptoms  are  often  not 
reliable,  while  the  early  cutaneous  and  mucous  lesions  are  practically 
pathognomonic.  The  greatest  objection  to  the  early  institution  of  treat- 
ment is  tlie  doubt  which  may  be  left  in  the  mind  (jf  both  physician  and 
patient  of  the  correctness  of  the  diagnosis  by  the  early  disappearance  of 
the  initial  lesion  and  the  local  adenitis.  The  individual  affected,  as  well 
as  the  practitioner,  is  too  often  lulled  into  a  sense  of  security  by  the 
rapid  disappearance  of  the  early  symptoms  ;  treatment  is  either  discon- 
tinued or  carelessly  carried  out  until,  after  several  weeks  or  months,  it  is 
discovered  that  the  disease  has  taken  a  firm  hold  ujjon  the  tissues. 

Commencing  with  this  date,  the  management  of  a  case  of  syphilis 
should  be  carried  on  for  a  jieriod  of  two  years. 

It  is  of  the  utmost  importance  that  the  person  affected  should  be  im- 
pi'essed  with  the  gravity  of  the  situation  and  the  certainty  of  disaster  if 
the  rules  laid  down  by  the  medical  adviser  are  not  strictly  obeyed.  With 
the  proviso  of  obedience,  the  prognosis  should  be  as  encouraging  as  pos- 
sible. Responsibility  for  the  result  of  treatment  in  this  disease  should 
not  be  assumed  unless  the  patient  consents  to  keep  himself  under  ob- 
servation for  the  period  above  given.  All  excesses  should  be  prohibited. 
The  use  of  tobacco  should  not  be  permitted.  Alcohol  in  any  shape  is 
scarcely  allowable.  In  certain  cases,  where  digestion  and  assimilation 
are  impaired,  a  small  quantity  of  whisky,  claret,  or  sherry  may  be  taken 
with  the  heaviest  daily  meal.  Sexual  indulgence,  if  from  no  other  than 
humanitarian  motives,  should  cease  for  at  least  a  year  from  the  appear- 
ance of  the  initial  lesion.  The  child  of  parents,  either  of  whom  is  within 
the  first  year  of  syphilitic  inoculation,  becomes  the  victim  of  a  dyscrasia 
which,  if  not  fatal  to  life,  is  fatal  to  the  i^erfect  usefulness  of  its  pos- 
sessor. 

In  addition  to  the  danger  of  direct  inoculation  during  the  prevalence 
of  the  chancre,  is  that  of  infection  to  the  mother  from  the  foetus  in  utero 
or  the  child  in  the  act  of  parturition.  A  patient  iinder  treatment  for 
syphilis  should  retii'e  early  and  at  a  regular  hour,  avoid  excessive  use 


TREATMENT  OF  SYPHILIS.  659 

of  the  eyes,  especially  at  night,  sudden  changes  in  temperature,  and  all 
articles  of  diet  which  are  not  readily  digestible. 

Of  the  preparatifins  of  mercury,  preference  should  be  given  to  the 
protoiodide.  It  is  conveniently  administered  in  pills  of  one-quarter  grain 
each.  To  begin  with,  one  of  these  pills  should  be  given  three  times  a 
day  one  hour  after  eating.  The  indications  for  a  diminution  in  the  quan- 
tity are  pain  of  a  cramp-like  nature  in  the  stomach  or  bowels,  with  or 
without  diarrhoea,  and  the  occurrence  of  salivation.  If  diarrha^a  results, 
it  will  be  advisable  to  administer  about  one-quarter  grain  of  opium  with 
each  pill  of  protoiodide,  or  to  reduce  the  daily  number  of  the  pills. 
Under  such  conditions,  inunctiims  with  mercurial  ointment  are  of  great 
value.  Salivation  may  be  guarded  against  by  careful  observation  of  the 
gums.  At  the  earliest  indications  of  tenderness  felt  when  the  teeth  ai'e 
lirmly  pressed  together,  or  when  direct  pressure  is  made  ujion  the  alve- 
olus, the  dose  should  be  diminished,  or,  if  necessary,  discontinued  for  a 
few  days. 

It  will  usually  suffice  to  administer  one-quarter  grain  three  times  a 
day  for  the  first  month,  and  at  the  expiration  of  this  time  to  increase  the 
daily  quantity  to  gr.  j.  It  will  rarely  be  necessary  to  give  more  than 
this  quantity,  although  in  some  cases  the  full  beneficial  effects  of  the 
remedy  may  not  be  realized  until  a  larger  daily  dose  is  given.  The  mer- 
cury should  be  continued  M'ithout  interruption — excepting  for  the  reasons 
Just  given — for  the  first  six  months  after  commencing  the  treatment.  At 
the  expii'ation  of  this  period  it  is  a  good  jAan  to  discontinue  the  proto- 
iiidide  for  two  weeks,  and  then  administer  the  iodide  of  potassium  in 
doses  of  grs.  x-xx  three  times  a  day  for  one  month.  This  should  in 
time  be  stopped,  and  the  piUs  resorted  to  for  a  period  of  two  months, 
and  so  on,  alternating  these  two  remedies  to  the  end  of  the  first  year  of 
treatment.  For  the  first  six  months  of  the  second  year  the  alternation 
should  be  equal — i.  e.,  one  month  of  the  potassium  salt,  and  the  next 
the  protoiodide.  For  the  last  six  months  of  treatment  a  greater  propor- 
tion of  the  iodide  of  potassium  should  be  given. 

In  addition  to  the  foregoing  it  is  of  great  importance  that  tonics 
should  be  administered  from  the  commencement  of  the  disease,  and 
especially  in  delicate  patients.  In  carrying  out  this  part  of  the  treat- 
ment much  better  results  will  be  obtained  in  the  alternate  exhibition  of 
several  tonics  rather  than  in  the  continued  use  of  a  single  remedy.  A 
l)reiwiration  of  iron,  quinia,  and  strychnia  on  one  day,  given  in  the  iinqier 
dose  immediately  after  each  meal ;  an  emulsion  of  cod-liver  oil  with  the 
liypophosphites  of  lime  and  soda,  each  gr.  j  to  the  tablespoonful  on  the 
next  day  ;  and  tincture  of  the  chloride  of  iron  on  the  third  day,  will  be 
found  a  convenient  and  useful  method  of  rotation. 

When  protoiodide  of  mercury  can  not  be  obtained,  the  biniodide,  in 
doses  of  gr.  -^  to  Jg^,  or  chloride  of  mercury  (corrosive  sublimate),  gr. 
2'o~r(i"iV  ™^3^  '^e  substituted. 

If,  for  any  reasons,  mercurial  inunctions  become  necessary,  proceed 
as  follows :  Take  about  a  teaspoonful  of  mercurial  ointment  and  rub  it 
well  into  the  skin  of  the  groin  and  under  the  arms.     Or  spread  the  oint- 


660  A  TEXT-BOOK   ON   SURGERY. 

ment  on  lint  and  apply  it  to  these  parts,  holding  it  in  jjlace  by  lif^htly 
fitting  clothes  or  bandages.  It  should  be  used  only  at  night,  and  re- 
moved upon  I'ising  by  washing  with  wnrm  wat(>r  and  soa]). 

The  hypodermic  injection  of  corrosive  subliniate  in  the  treatment  of 
syphilis  is  objectionable  on  account  of  the  annoyance  produced  by  the 
insertion  of  the  solution  beneath  the  integument.  It  is  an  unnecessary 
practice,  for  the  best  results  can  be  obtained  from  the  internal  adminis- 
tration of  the  protoiodide. 

In  the  treatment  of  the  tertiary  lesions  of  syphilis,  practically  the 
same  rule  of  practice  should  be  adopted  as  just  given  for  tlie  second 
year  following  the  ap])earance  of  the  initial  lesion.  The  employment  of 
iodide  of  potassium  in  full  doses  hastens  the  absorption  of  the  inflamma- 
tory ])roducts  of  this  stage,  while  the  protoiodide  destroys  the  potency 
of  the  virus.  Both  remedies  should  be  administered  in  doses  as  large 
as  can  be  borne  without  interfering  with  the  functions  of  the  digestive 
organs  or  producing  any  serious  constitutional  disturbances. 

Inhcritt'd  SypJiJlls. — The  f(rtus  may  beccmie  syphilitic  from  a  syphi- 
litic father  or  mother.  If  pregnancy  occurs  within  the  first  year,  and 
especially  in  the  first  six  months  of  the  disease  in  the  mother,  the  child 
becomes  inoculated,  eitlier  dying  in  utcro,  or,  if  carried  to  term,  usually 
perishes  within  a  few  weeks  after  its  birth.  If,  however,  the  disease  is 
recognized  and  i)roper  treatment  instituted,  a  more  favorable  prognosis 
may  be  nuide. 

In  the  second  year  after  infection,  if  properly  treated,  a  mother  may 
bear  a  non-syphilitic  child,  although  the  chances  are  against  complete 
immunity.  During  the  third  and  each  succeeding  year,  under  judicious 
management,  the  prognosis  is  still  more  favorable. 

A  female  patient  should  be  advised  of  the  great  danger  of  pregnancy 
within  the  two  years  immediately  following  inoculation.  When  she  has 
been  under  constant  and  in-ojier  treatment  for  this  length  of  time,  and 
has  been  perfectly  free  from  symptoms  for  one  year,  the  gravity  of  the 
danger  is  diminished.  If  she  has  not  been  treated,  she  should  under  no 
circumstances  be  made  liable  to  pregnancy.  In  case  such  a  woman 
should  become  pregnant,  she  should  be  treated  carefully  for  syi)hilis,  and 
in  this  way  the  infection  of  the  child  may  be  modified,  if  not  prevented. 

The  virus  of  syjihilis  may  be  conveyed  by  the  spermatic  elements, 
and  the  embryo  thus  become  inoculated.*  The  prognosis  is  more  favor- 
able in  proi)ortion  to  the  length  of  time  which  has  elapsed  after  the 
initial  lesion,  and  to  the  thoroughness  of  the  treatment  instituted.  A 
syphilitic  man  should  not  beget  a  child  within  two  years  after  the  initial 
sore,  nor  at  any  later  period  unless  thorough  treatment  has  been  insti- 
tuted and  one  year  has  elapsed  since  the  disappearance  of  all  symp- 
toms of  the  disease. 

*  As  heretofore  stateJ,  a  non-sypliilitic  mother  may  be  inoculated  from  a  syphilitic  child  in 
the  act  of  parturition.  That  the  mother  is  also  subjected  to  the  influence  of  this  virus  from 
carrying  the  offspring  of  a  syphilitic  father  is  proved  by  CoUex's  law,  which  is,  that  a  previously 
healthy  mother  of  such  a  child  can  nurse  it  without  danger  of  chancre  of  the  niiiplo  and  syphi- 
litic infection,  wliile  a  non-syphilitic  nurse  will  become  inoculated. 


INHERITED  SYPHILIS.  661 

Symptoms. — The  symptoms  of  specific  infection  in  the  child  manifest 
themselves  usually  within  the  first  eight  or  twelve  weeks  after  birth.  Oc- 
casionally the  disease  is  latent,  and  tlie  symptoms  do  not  appear  until 
a  variable  period  has.elapsed.  Even  puberty  may  be  reached  before  it  is 
evident.  Excepting  the  chancre,  the  local  lymphangitis  and  adenitis,  the 
evolution  of  the  symptoms  of  inherited  syj^hilis  is  not  unlike  those  of  the 
acquired  form.     The  lesions  are  cutaneous,  mucous,  and  visceral. 

The  macular  or  papular  syphilide  occurs  in  most  cases,  and  may  be 
distributed  over  the  general  surface  or  confined  to  certain  limits.  It  is 
usually  first  seen  upon  the  abdomen,  and  from  this  starting-point  it  be- 
comes more  or  less  widely  distributed.  At  the  muco-cutaneous  margins, 
and  in  the  folds  of  the  skin  where  irritation  is  greater  and  moisture 
exists,  condylomata  are  not  infrequent,  and  are  often  persistent.  Vas- 
cular, pustular,  and  tubercular  syphilides  occur  in  a  certain  proportion 
of  cases.  The  tubercular  form  is  rare.  The  pustular  form  (syphilitic 
pemphigus)  indicates  a  low  order  of  tissue  vitality,  and  justifies  an  un- 
favorable prognosis. 

Lesions  of  the  mucous  surfaces  occur  either  before  or  with  the  cuta- 
neous lesibns.  Papules  and  excoriations  (mucous  patches)  are  found  in 
the  buccal  cavity,  on  the  tongue,  fauces,  and  jjliarynx.  Fissures  of  the 
lips  are  not  uncommon,  and  especially  in  the  angles  of  the  mouth.  The 
infection  of  the  mucous  membrane  of  the  nose  and  air-passages  leads  to 
the  distressing  coryza  and  cough  so  often  noticed  in  syphilitic  infants. 
Gummata  of  the  skin  and  of  all  organs  occur  in  the  same  manner  and 
with  the  same  pathological  significance  as  in  the  acquired  form. 

Treatment. — The  pi-eparations  of  mercury  antagonize  the  virus  in  this 
as  in  the  acquired  form  of  syphilis.  The  careful  mercurialization  of  the 
mother  during  pregnancy  is  important  in  preventing  the  development  of 
the  disease  in  its  severer  forms.  Inunction  with  the  ointment  of  mer- 
cury should  be  fiist  faithfully  tried  in  the  treatment  of  syphilis  in  the 
newly-born.  One  drachm  of  mercury  to  one  ounce  of  lard  is  the  pro- 
portion recommended  by  Brodie.  This  is  spread  upon  a  soft  flannel  belt 
and  worn  continuously  around  the  patient's  waist.  The  ointment  should 
be  renewed  as  needed.  If  the  beneficial  efi'ects  of  the  mercury  are  not 
secured  by  this  method,  the  internal  administration  may  be  resorted  to, 
but  in  no  case  until  after  a  thorough  trial  of  the  inunctions.  The  bin- 
iodide  of  mercury,  in  doses  of  tt^  grain,  in  combination  with  one- quar- 
ter grain  of  the  iodide  of  potassium,  is  advisable  to  begin  with.  The 
dose  may  be  carefully  increased  if  necessary.  The  nourishment  of  the 
child  should  be  most  carefully  attended  to,  and  it  should  have  the  bene- 
fit of  pure  air  and  comfortable  surroundings. 

Scrotum.— Wounds  of  the  scrotum  should  be  treated  as  similar  le- 
sions elsewhere.  On  account  of  the  great  vascularity  of  the  tissues,  re- 
]iair  is  usually  rapid.  The  contractility  of  the  dartos  and  cremaster 
muscles  will  prevent  early  union  unless  the  stitches  are  closely  ai)])lied. 
If  the  testicle  is  protruded,  it  should  be  disinfected  with  1-to-lOOOO  sub- 
limate, returned  to  its  normal  iiositiou,  and  the  cavity  of  the  tunica  vagi- 
nalis also  washed  out  with  the  sublimate  solution.    In  closing  the  woiind 


662  A  TEXT-BOOK  ON   SURGERY. 

with  catgut  sutures,  the  edges  of  the  opening  in  the  tunica  should  bo 
inchided.  A  small  bone  or  catgut  drain  should  be  inserted  into  the 
cavity  and  emerge  at  the  lower  augl(>  of  the  incision. 

Contusions  should  be  treated  by  rest  in  the  horizontal  posture,  cold 
applications  and  mechanical  support  beneath  the  posterior  aspect  of  the 
scrotum. 

(Edema  of  the  scrotum  occurs  with  general  anasarca  and  with  ascites. 
The  integument  is  tense,  pale,  and  doughy  ;  pits  upon  pressure,  and, 
lifter  puncture  with  tlie  hypodermic  needle,  a  clear,  watery  serum  es- 
capes. Besides  the  indications  for  constitutional  treatment  directed  to 
the  disease  proper,  puncture  with  the  lancet  in  several  points  will  tem- 
I)orarily  relieve  the  tension  and  danger  of  gangrene. 

Eczema  and  other  cutaneous  lesions  of  the  scrotum  do  not  demand 
especial  consideration.  The  same  general  principles  of  treatment  ai)i)ly 
with  equal  force  to  all  the  cutaneous  surface.  The  prognosis  is  unfavor- 
able on  account  of  the  irritation  to  which  this  organ  is  subjected  fnmi 
friction  with  the  clothing  and  thighs,  and  especially  owing  to  the  peris- 
taltic movements  of  the  dartos  and  cremaster  muscle. 

Cysts,  due  chiefly  to  the  retention  of  sebum,  are  occasionally  seen  in 
the  scrotum.  They  are  usually  situated  near  the  raphe,  or  laterally  and 
posteriorly  upon  the  base  of  the  scrotum.  When  large  enough  to  cause 
inconvenience,  incision  and  extirpation  of  the  sac  are  demanded. 

Erysipelas,  although  rare  in  this  jjortion  of  the  body,  is  met  with, 
and  is  often  obstinate  under  treatment.  Oangrene  is  one  of  the  chief 
dangers,  and  must  be  guarded  against  by  free  incision  as  soon  as  the 
tension  is  great.  Phlegmon  of  the  scrotum  should  be  treated  by  warm 
applications,  poultices,  etc.,  and  by  early  incisions  to  relieve  tension  and 
give  escape  to  septic  matter.  Free  drainage  and  sublimate  irrigation  are 
indicated. 

Elephantiasis  scroti,  comparatively  of  rare  occurrence  in  the  tem- 
perate and  colder  zones,  is  frequently  met  with  near  the  equator  ;  and  in 
some  of  the  West  Indies  and  the  islands  of  the  South  Pacific  Ocean  it 
occurs  with  great  frequency. 

The  pathology  of  this  foim  of  connective-tissue  hyperplasia  has  been 
given.  The  cause  is  undoubtedly  one  of  prolonged  irritation.  The  only 
treatment  is  extirpation  with  the  knife.  No  fixed  rule  of  operating  can 
be  laid  down.  The  penis  is  at  times  buried  in  the  neoplasm,  and  should 
be  carefully  dissected  out.  The  incisions  should  be  made  so  as  to  give  a 
cutaneous  flap  in  front  and  behind  sufficiently  large  to  contain  the  testes 
and  cord  without  pressure  after  the  connective-tissue  new  formation  has 
been  dissected  out.  AVhen  the  penis  is  included  in  the  new  growth,  the 
integument  should  be  saved,  to  cover  this  organ.  If  this  can  not  be 
done,  flaps  may  be  turned  from  the  thighs  and  abdomen. 

The  h{emorrhage  in  this  procedure  may  be  controlled  by  working  be- 
tween fixation-forceps,  or  by  the  adjustment  of  an  elastic  tcmrniquet 
around  the  scrotum  near  its  attachment  to  the  perinseum. 

Angioma  of  the  scrotum  is  rare,  and  demands  treatment  similar  to 
that  advised  in  the  chapter  on  these  vascular  formations. 


HEMATOMA— PERIORCHITIS  AXD  PERISPERMATITIS.      663 

Epithelioma  is  more  frequently  seen  than  either  of  the  foregoing 
neoplasms,  and  calls  for  immediate  excision. 

Fistulcr,  or  sinuses  of  the  scrotum,  may  be  caused  by  abscess  of  the 
tunica  vaginalis  tesris,  or  by  any  lesion  of  the  testicle.  Abscess  of  the 
perinseum  or  urinary  fistula  may  also  cause  fistula  of  the  scrotum. 
Stony  concretions  are  occasionally  met  with  in  fistulge  of  the  scrotum 
through  which  the  urine  makes  its  escajse. 

The  treatment  should  be  directed  to  a  relief  of  the  cause  of  the  fis- 
tulous tracks.  If  this  is  accomplished,  the  sinuses  should  be  laid  open 
and  allowed  to  close  by  granulation. 

HoRviatoma. — Extravasation  of  blood  may  occur  either  in  the  tunica 
funiculi,  in  the  tunica  vaginalis  testis,  or  in  both.  In  the  fomier  it  may 
be  diffuse  or  circumscribed.  It  is  usually  diffuse,  the  extravasation  ex- 
tending from  the  abdominal  opening  to  the  epididymis.  AVhen  only  a 
portion  of  the  sheath  is  involved,  the  heematoma  is  generally  confined 
to  the  upper  segment. 

The  chief  causes  of  extravasation  are  rupture  of  one  or  more  vessels 
by  direct  traumatism,  or  by  over-distention  from  prolonged  strain,  which 
retards  the  return  cii'culation,  causing  rupture  of  a  vein. 

Haematoma  of  the  tunica  vaginalis  testis  is  rare,  except  as  a  compli- 
cation of  chronic  periorchitis  serosa  (hydrocele)  or  direct  violence. 

The  diagnosis  of  ha:'matoma  in  either  of  these  positions  depends  upon 
its  sudden  development,  the  tendency  to  enlarge  progressively,  and  pain 
from  the  sudden  distention.  The  tumor  is  not  translucent.  The  exact 
nature  may  be  determined  by  aspiration. 

Serous  effusion  (hydrocele)  into  the  sheath  of  the  cord  or  testis  pro- 
gresses slowly  and  painlessly.  The  tumor  is  translucent.  Exploi-ation 
with  the  hypodermic  needle  and  syringe  is  a  safe,  painless,  and  positive 
means  of  diagnosis. 

Hernia  may  be  eliminated  by  a  consideration  of  the  history  of  the 
case  and  the  absence  of  impulse  in  the  tumor  upon  coiighing. 

Treatment. — Hsematocele  may  be  treated  by  the  exjjectant  method,  or 
by  surgical  interference. 

Simple  and  limited  extravasation  requires  rest  in  the  dorsal  decu- 
bitus, and  the  ice-bag  locally.  After  the  hferaorrhage  is  arrested,  absorp- 
tion may  be  expedited  by  judicious  and  weU-applied  pressure  by  strap- 
ping. When  the  extravasation  is  extensive,  an  incision  should  be  made 
under  strict  antisepsis,  the  clot  turned  out,  the  bleeding-point  ligated, 
drainage  secured,  and  the  wound  closed.  Death  has  followed  in  some 
instances  where  operative  procedure  has  been  too  long  delayed. 

Periorchitis  and  Perispermatitis. — Inflammation  of  the  serous  in- 
vestments of  the  spermatic  cord  and  testicle  may  be  circumscribed  or 
diffuse.  An  inflammation  commencing  from  a  lesion  of  the  external  or 
scrotal  layer  usually  involves  the  entire  sac,  as  does  the  similar  process 
beginning  on  the  visceral  reflection  of  the  tunica. 

Perispermatitis  may  be  acute  or  chronic.  A  type  of  the  acute  in- 
flammation is  seen  in  severe  forms  of  epididymitis,  or  as  the  result  of 
direct  violence.     The  transudation  of  serum  may  be  limited,  and,  as  in 


664 


A  TEXT-BOOK   ON   SURGERY 


pleurisy,  adhesions  may  occur  with  obliteration  of  the  sac,  or  suppura- 
tion may  ensue ;  or,  passing  into  a  subacute  and  chronic  stage,  a  condi- 
tion of  true  hydrocele  of  tlie  cord  ensues  {perispermatitis  chronica 
serosa). 

Effusion  into  the  sheath  of  the  cord  may  communicate  with  the  cavity 
of  the  tunica  vaginalis  testis  (Fig.  654),  or  with  the  peritoneal  cavity 


Fio.  (154.— Hydrocele  of  the 
cord  communicating  with 
tlieiuuica  vaginalis  testis. 
Tlie  instrument  is  passed 
throuirh  the  membrane 
wliicli  separates  the  fluid 
from  the  neritoHceum.  r/, 
Testis.     (Alter  Linhart.  i 


Fig.  fi.'i.'i. — c,  Hydro- 
cele ot'the  cord  eom- 
municatinu;  with  the 
peritoneal  cavity,  ii, 
Testis.  (After  Liu- 
hart.  ) 


Fig.  656.— Encysted 
hydrocele  of  the 
cord. 


Fio.  CiV. — Hydrocele 
of  the  tunica  vagi- 
nalis testis.  (After 
Linhart.) 


(congenital  hydrocele)  (Fig.  O.lo),  but  these  conditions  are  rare.  It  is 
usually  confined  to  the  tunica  funiculi  (Fig.  656). 

The  diagnosis  of  this  form  of  hydrocele  rests  upon  the  recognition 
of  a  fluctuating  tumor  in  the  line  of  the  cord,  and  the  exclusion  of  hsema- 
tocele,  varicocele,  and  hernia. 

The  symptoms  of  lijematocele  have  just  been  given.  The  peculiar 
feel  of  a  varicocele,  so  well  compared  to  the  sensation  felt  in  grasping  a 
mass  of  eartli-wonns  between  the  fingers,  can  scarcely  be  mistaken.  If 
the  recumbent  posture  is  assumed,  the  varicose  veins  are  emptied  and 
'  the  tumor  disappears.  This  can  not  occur  in  cyst  of  the  cord.  A  hernial 
tumor  gives  the  characteristic  impulse  upon  coughing  ;  a  cyst  does  not. 
A  reducible  hernia  will  disappear  in  the  recumbent  posture,  and  if,  when 
reduced,  the  finger  is  pressed  into  the  iiiternal  ring,  it  will  not  recur, 
while,  despite  this  precaution,  a  varicocele  will  reappear.  Exploration 
with  a  hyi)odermic  needle  will  disclose  the  character  of  the  contents. 
The  treatment  of  hydrocele  of  the  spermatic  cord  is  practically  the  same 
as  that  for  hydrocele  of  the  tunica  vaginalis  testis. 

Periorchitis  may  also  be  acute  or  chronic.  In  acute  Inflammation  the 
quantity  of  serous  transudation  may  be  large  or  small.  When  the  in- 
flammatory process  is  acute,  and  the  transudation  of  serum  so  limited 
that  the  opposing  surfaces  of  the  two  walls  are  not  kept  ai)art,  adhe- 
sions may  occur,  with  partial  or  complete  obliteration  of  the  sac. 

The  causes  include  all  lesions  of  the  scrotum,  the  testicle,  and  epi- 
didymis, the  process  naturally  extending  to  the  delicate  lining  membrane. 


PERIORCHITIS. 


665 


Chronic  epididymitis  and  orchitis  should  rank  as  first  in  the  aetiology 
of  hydrocele.  The  interference  of  the  return  circulation  here  will  pro- 
duce the  transudation  of  fluid  in  the  same  way  as  ascites  occurs  in  cir- 
rhosis of  the  liver.  In  like  manner  varicosities  in  the  veins  of  the  sper- 
matic plexus  may  induce  hydrocele.  The  pathological  changes  consist 
in  a  general  thickening  of  the  visceral  and  parietal  layers  of  the  tunica, 
due  to  the  development  of  connective- tissue  elements  in  which  new  ves- 
sels are  formed. 

Nut  infrequently  little  pearl-like  bodies  are  seen  attached  to  the  vis- 
ceral surface  of  the  thickened  tunica,  or  they  may  be  found  floating  free 
in  the  fluid  of  the  sac.  They  are  made  up  of  connective-tissue  and  flat- 
tened ei^ithelial  elements.  Occasionally  they  undergo  the  calcareous 
metamorphosis.  The  sac  of  a  hydrocele  of  the  tunica  vaginalis  testis  is 
almost  always  unilocular  (Fig.  658),  but  in  rare  instances  it  is  bilocular, 
with  a  narrow  opening  of  communication  between  the  sacs  (Fig.  659). 
The  dividing  septum  is  made  up  of  the  products  of  inflammation. 


Fig. 


658. — Usual  form  of  hydiooele 
(After  Kocher.) 


Fig.  659. — Bilocular  hydrocele.  Tc,  Parietal 
layer  of  tunica.  A',  Spermatic  cord.  J\' h. 
Epididymis.  H,  Testis.  Z>,  Cavity  of 
diverticulum.  Tt,  Cavity  of  tlie  tunica 
vacrinalis  proprius.  Zz^  Inflammatory 
new  formation  between  tlie  visceral  and 
parietal  layers.     {After  Koulier.) 


The  fluid  of  hydrocele  is  amber  in  color,  or,  if  blood  has  been  ex- 
travasated  and  mixed  with  it,  it  may  be  brownish-black  or  red.  Under 
the  microscope  it  is  seen  to  contain  compound  granular  corpuscles,  leu- 
cocytes, swollen  endothelia,  and  at  times  crystals  of  cholesterin  and  red- 
blood  disks. 

S//mpfoms. — Hydrocele  of  the  tunica  vaginalis  testis  is  usually  single 
— at  times  double.  In  shape  the  tumor  is  usually  pyriform  or  oval,  with 
the  largest  diameter  of  the  swelling  l^elow.  Tt  may,  however,  assume  a 
conical  sliape,  with  the  apex  downward,  as  shown  in  Fig.  660.  The  his- 
tory is  generally  that  of  a  slow  and  painless  swelling,  first  noticed  in 
the  lower  portion  of  tlie  scrotum,  and  gradually  extending  upward.  In 
size  it  may  vary  from  a  mass  having  a  long  diameter  of  an  inch  or  two, 


666 


A   TEXT-BOOK   ON  SURGERY. 


to  as  niiioh  as  ten  or  twelve  inches.  In  recent  oases  the  walls  are  thin, 
fluctuation  is  easily  made  out,  and  the  testicle  may  be  recognized  in  the 
lower  posterior  portion  of  the  swelling.  In  old  cases  the  walls  may 
measure  half  an  inch  or  more  in  thickness,  and  are  so  tense  and  in- 
elastic that  to  the  touch  the  tumor  seems  wholly  solid.     The  dilferentia- 

tion  includes  hydrocele  of  the 
cord,  encysted  hydrocele  of  the 
testis,  hernia,  varicocele,  and  va- 
rious neoplasms  or  swellings  of 
the  testis  and  epididymis. 

Hydrocele  of  the  cord  is  ob- 
long or  spherical  in  shape,  usu- 
ally of  small  size,  and  gives  a  his- 
tory of  a  swelling  commencing 
above  tlie  testicle,  which  organ 
can  be  made  out  by  palpation  be- 
low the  tumor.  Encysted  hydro- 
cele of  the  testicle  can  only  defi- 
nitely be  made  cmt  by  i)uncture 
with  the  aspirator-needle  and  ex- 
amination of  the  contents  with 
tiie  microscope.  The  ])resence  of 
the  spermatozoa  will  determine 
the  encysted  character  of  the  tu- 
mor. In  hernia  the  swelling  be- 
gins at  the  inguinal  ring,  and 
travels  progressively  downward. 
If  reducible,  it  can  be  made  to 
disappear  by  assuming  the  dor- 
sal decubitus,  while  a  hydrocele 
would  be  unaffected  by  this  ma- 
nttMivre.  Percussion  upon  an  in- 
testinal hernia  will  yield  resonance,  while  that  upon  the  tumor  of  hydro- 
cele gives  dullness.  Omental  hernia  is  doughy  to  the  feel,  while  hydro- 
cele is  tense  and  resisting.  Varicocele  can  be  eliminated  by  the  peculiar 
impression  conveyed  to  the  fingers  when  the  worm  like  veins  are  grasped. 
The  solid  character  of  neoplasms  of  the  testis  or  epididymis  can  be 
recognizt^d  by  palpation.  Of  most  importance,  however,  is  the  employ- 
ment of  the  exploring  aspirator,  which  safely  and  easily  deuioustrates 
the  liquid  character  of  the  contents  of  hydrocele. 

Treat  me  lit  .—The  cure  of  hydrocele  is  effected  in  almost  all  cases  by 
operative  interference.  The  transudation  of  serum  into  the  cavity  of 
the  tunica  vaginalis  testis,  symptomatic  of  specific  disease,  or  any 
acute  local  affection,  may  disappear  by  absorption  under  proper  medi- 
cal treatment,  or  after  the  disai)pearance  of  the  acute  trouble.  These 
cases  are,  however,  exceptional  ;  and,  if  absorption  does  not  occur 
within  the  first  few  weeks  of  the  history  of  the  affection,  operation  is 
demanded. 


Fig.  cr.n. — Double  hydrocele  of  the  tunicft  vaciimlis 
testis.  (From  a  patient  operated  upon  at  ilount 
Sinai  Hospital.) 


PERIORCHITIS.  667 

The  operative  procedures  are  two  iu  number— 1,  by  injection,  and  2, 
by  incision.  The  former  method  should  be  preferred  in  all  cases  of 
recent  formation,  in  which  there  is  not  great  thickening  of  the  walls, 
and  in  which  the  sac  is  not  very  large.  It  may  be  safe  to  include  in  this 
category  all  cases  in  which  the  long  diameter  of  the  tumor  is  not  more 
than  five  inches,  and  in  which  the  depth  of  tissue  between  the  integu- 
ment of  the  scrotum  and  the  cavity  of  the  sac  is  not  more  than  half  an 
iach.  If  this  procedure  fails,  it  should  be  repeated  once  or  twice  be- 
fore the  more  formidable  procedure  known  as  Volkmann's  operation  is 
undertaken. 

First  Metftod — Levis^s  Operation.— Hhaxe  the  tumor  on  its  anterior 
aspect,  and  cleanse  the  integument  thoroughly.  Inject  from  m  x-xv  of 
a  4-per-cent  cocaine  solution  in  such  a  way  that  local  anfesthesia  will  be 
obtained  through  the  depth  of  the  wall  of  the  sac  throughout  an  area  of 
half  an  inch  in  diameter.  Twenty  minims  of  pure  carbolic  acid  should 
now  be  placed  in  the  syringe,  and  a  long  needle  attached.  Place  the 
patient  upon  the  back,  separate  the  thighs,  have  a  pus-basin  convenient, 
support  the  tumor  with  the  left  hand,  making  the  parts  tense  by  press- 
ure ;  take  a  trocar-canula  in  the  right  hand,  firmly  seized  between  the 
thumb  and  finger  one  inch  from  the  point  (so  that  it  may  not  possibly 
be  thrust  in  farther  than  this  limit) ;  remember  that  the  testicle  is  be- 
hind and  below,  and  with  a  quick  and  accurate  thrust  carry  the  instru- 
ment through  the  ansesthetized  zone  into  the  cavity  of  the  sac.  The 
point  of  entrance  should  be  about  one  third  of  the  distance  from  the 
lower  portion  along  the  anterior  aspect  to  the  upper,  and  the  direction 
of  the  shaft  of  the  trocar  should  be  upward  and  somewhat  backward. 
Upon  removal  of  the  stylet  the  liquid  rapidly  escapes  through  the  can- 
ula,  any  remnant  being  forced  out  by  compression.  Care  must  be  taken 
not  to  shift  the  canula  from  its  first  position.  When  the  fluid  is  emptied, 
carry  the  hypodermic  needle  into  the  canula,  and  force  the  carbolic  acid 
into  the  sac  ;  withdraw  the  needle,  and  then  the  canula,  and  knead  the 
scrotum  and  sac  so  as  to  distribute  the  acid  over  the  entire  surface. 
This  operation  is  almost  without  pain.  In  some  instances  a  slight  sense 
of  faintness  is  experienced  just  as  the  acid  is  injected.  The  patient 
should  be  kept  quiet  on  the  day  of  the  operation,  but  with  proper  sus- 
pension of  the  scrotum  he  may  be  allowed  to  move  about  after  twenty- 
four  hours.  On  the  day  following,  and  for  about  a  week  afterward,  the 
tumor  swells  up  as  if  it  were  refilling,  and  is  solid  or  doughy  to  the  feel. 
After  this  it  begins  to  decrease  until  tlie  sac  is  obliterated  and  a  per- 
manent cure  is  effected.  A  scrotal  wall  and  the  investing  serous  mem- 
brane of  the  testicle  which  i.s  once  thickened  becomes  somewhat  thinner 
after  the  cure  of  the  hydrocele,  but  never  entirely  resumes  its  natural 
thickness. 

Second  Mdhod — Volkmnnn's  Operation. — Shave  the  scrotum  and 
pubes,  narcotize  the  patient  with  ether,  and  over  the  anterior  middle 
line  of  the  side  affected  make  an  incision  varjong  in  length  with  the  size 
of  the  tumor  and  the  thickness  of  the  wall.  Usually  an  incision  from 
two  to  foui-  inches  in  length  will  suffice.     Cut  directly  down' until  the 


668  A  TEXT-HOOK   ON   SURGERY. 

sac  is  reached,  and  incise  this  to  about  the  same  extent  as  for  the  wound 
in  the  integument,  allow  the  fluid  to  escape,  and,  with  a  good-sized  cat- 
gut continuous  suture,  stitch  the  cut  edge  of  tli(»  parietal  layer  of  the 
tunica  vaginalis  testis  to  the  edge  of  the  wound  in  the  skin,  making  an 
opening  not  unlike  a  button-hole.  Irrigate  the  sac  with  l-to-3()00  subli- 
mate solution,  and  insert  a  rubber  drainage-tube  into  the  u])per  and 
lower  portions  of  the  cavity,  and  apply  a  sublimate-gauze  dressing. 

In  all  antiseptic  dressings  about  the  penis  it  is  essential  to  isolate 
this  organ  so  that  the  urine  or  the  usual  unclean  condition  of  this  or- 
gan may  not  infect  the  wound.  To  do  this  after  the  drainage  is  secured 
and  the  first  gauze  is  placed  around  the  tubes  along  the  edges  of  the 
button-hole,  make  a  hole  in  all  the  layers  of  sublimate  gauze  and  the 
sheet  of  protective  large  enough  for  the  penis  to  pass  through  without 
constriction.  Lastly,  tuck  the  dressing  well  iip  under  the  scrotum  close 
to  the  perinaMim,  to  keep  the  gases  and  fecal  discharges  from  infecting 
the  wound.  This  operation  will  cure  any  case  of  hydrocele  which  will 
not  yield  to  the  more  conservative  procedure  of  Levis.  It  can  only  be 
dangerous  by  neglect  of  careful  drainage.  In  very  large  sacs  a  counter- 
opening  should  be  made  through  the  lower  portion.  Such  wounds 
rarely  require  more  than  one  or  two  changes  in  the  dressings,  and  only 
then,  as  in  all  surgical  wounds,  when  the  discharge  soils  the  dressings, 
escapes  beyond  the  area  of  antisepsis,  and  becomes  offensive  by  decom- 
position, or  when  the  rise  in  temperature  indicates  the  ja-esence  of  sep- 
tic absorption. 

Bone-drains  may  be  used  in  the  smaller  tumors,  but  rubber  gives  a 
better  guarantee  of  perfect  drainage. 

Suppurating  periorchitis,  or  pus  in  the  cavity  of  the  tunica  vaginalis, 
may  be  treated  by  two  methods :  If  the  temperature  is  high,  the  sac 
jiainful,  and  the  scrotum  swollen,  the  indications  are  for  free  incision, 
irrigation,  and  drainage.  Under  less  threatening  conditions,  the  aspira- 
tor may  be  employed,  the  sac  emptied  and  rei^eatedly  injected  and  washed 
out  with  l-to-5000  sublimate  solution,  and  compression  ajjplied  afterward. 
In  this  way  obliteration  of  the  sac  may  be  achieved,  as  in  the  treatment 
of  cold  abscesses. 

Varicocele. — Varicosities  of  the  veins  of  the  spermatic  plexus  are  not 
uncommon.  Varicocele  is  chiefly  caused  by  gravity  and  the  mechanical 
interference  with  the  return  of  blood  through  the  spermatic  veins.  It 
occurs  with  greater  frequency  on  the  left  side,  where  the  vessels  are 
pressed  upon  by  the  sigmoid  flexure  of  the  colon  with  its  almost  constant 
weight  of  fecal  matter.  In  addition  to  this,  the  greater  length  of  the  left 
spermatic  vein,  which  enters  the  renal  vein  at  a  right  angle  to  its  axis, 
and  is  poorly  protected  by  valves,  are  causes  which  serve  to  produce 
varicosities  upon  this  side  more  frequently  than  in  the  right  plexus. 
Any  occupation  which  necessitates  the  erect  posture  is  apt  to  add  to  the 
susceptil)ility  of  this  disease.  Hereditary  tendencies  must  be  considered 
in  its  {etiology,  for  frequently  members  of  a  family  through  several  gen- 
erations will  be  affected. 

The  earlier  symptoms  are  a  feeling  of  heaviness  or  dragging  down  on 


VARICOCELE. 


669 


the  side  affected,  with  the  appearance  of  a  small  swelling  in  the  line  of 
the  cord.  Pain  is  variable,  and  is  sometimes  referred  to  the  cord  or  to 
the  inguinal  region  or  down  the  leg.  The  testicle  hangs  lower  than 
natural,  and  along  the  cord  can  be  felt  a  network  of  turgid  veins  extend- 
ing from  the  epididymis  toward  the 
external  ring.  To  the  touch  they  seem 
not  unlike  a  knot  of  earth-worms. 
The  swelling  is  apt  to  be  largest  at  the 
lower  extremity  (Fig.  661). 

The  diagnosis  is  not  difficult. 

The  swelling  of  inguinal  hernia  is 
spherical,  and,  when  composed  of  in- 
testine, it  is  resonant  on  percussion. 
If  the  hernia  is  reducible,  and  is  re- 
turned into  the  cavity  of  the  abdomen 
with  the  patient  in  the  recumbent 
posture,  and  if  the  index-tinger  is  car- 
ried into  the  internal  ring  and  held 
there  while  the  patient  is  made  to 
stand  erect,  the  veins  will  again  refill 
and  demonstrate  the  varicocele,  while 
the  hernia  will  be  prevented  from  de- 
scending. Hsematoma,  or  hydrocele 
of  the  cord,  can  be  recognized  by  as- 
piration with  the  hypodermic  syringe. 

Treatment. — Very  few  cases  of  vari- 
cocele require  operative  interference. 
A  well-adjusted  suspensory  apparatus 
constantly  worn  while  in  the  erect  post- 
ure will  obviate  the  necessity  for  an 
operation  in  the  vast  majority  of  in- 
stances. This  bag  may  be  made  to  include  and  support  only  one  half 
the  scrotum  and  a  single  testicle,  or  the  double  elastic  apparatus  may 
be  employed. 

"When  no  palliative  measures  are  effectual,  operative  interference  is 
demanded.  The  procedures  are  two  in  number,  namely — subcutaneous 
ligature  (Keyes),  or  incision  and  ligature  by  the  open  method.  Of  these 
two  operations,  the  former  is  far  preferable,  and  should  be  tried  repeat- 
edly before  resort  is  had  to  the  incision. 

First  Method— Keyes' s  Operation. — Shave  the  scrotum  and  pubes, 
and  thoroughly  wash  these  surfaces  with  ether  and  sublimate  solution. 
The  patient  is  made  to  stand  erect,  with  the  legs  separated,  in  order  to 
distend  the  veins.  In  cold  weather  it  may  be  necessary  to  have  him  sit 
in  a  tub  of  hot  water  to  induce  full  relaxation.  By  the  injection  of  co- 
caine, local  anpesthesia  should  be  obtained  in  the  parts  where  the  ligature 
is  to  be  inserted.     From  m  x-xx  of  a  4-per-cent  solution  will  suffice. 

The  ligature  should  be  of  Chinese  twisted  silk,  not  too  large,  but 
capable  of  bearing  all  the  strain  which  will  ordinarily  be  brought  against 


Fig.  6G1. — Varicosities  of  the  spermatic  plexus 
of  veins,  with  atrophy  of  the  testicle. 
(After  Kocher.) 


670  A  TEXT-BOOK  OX  SURGERY. 

it.  This  should  be  thoroughly  soakt'd  in  l-to-SOOO  siiblimate  solution 
for  several  hours  before  it  is  to  be  used.  For  jiassing  the  ligature  arouud 
the  mass  of  veins,  Keyes's  needle  (Fig.  602)  should  be  jireferred.  It  is 
better,  as  Avill  be  seen,  to  have  two  of  these  instruments.  If  these  can 
not  be  obtained,  the  long  needle  of  Peaslee,  or  an  ordinary  darning- 
needle,  may  be  substituted.     With  everything  in  readiness,  proceed  as 


T 

Fig.  662.  — Keyes's  varicoccle-iieeJle. 

follows:  The  operator,  by  careful  manipulation,  finds  the  vas  deferens 
as  it  is  located  in  tlie  posterior  part  of  the  cord  near  the  level  of  the 
scrotal  attachment  to  the  perinaeum,  separates  it  from  the  mass  of  veins, 
and,  by  tightly  pinching  the  scrotal  walls  between  the  thumb  and  finger 
of  the  left  hand,  holds  this  important  duct  behind  and  to  the  inner  side 
of  the  veins. 

Tlie  vas  deferens  may  be  recognized  by  its  dense  and  leathery  feel. 
It  i.s,  as  a  rule,  smaller  than  the  veins,  but,  while  these  may  ))e  effaced 
by  pressure,  the  vas  deferens  is  so  thick  that  it  can  not  be  obliterated, 
but  will  jump  from  between  the  tliumb  and  finger  when  tightly  squeezed. 
Once  eliminated  and  secured  behind  the  veins,  pressure  should  not  be 
interrupted  until  the  threaded  needle  is  passed  entirely  through  both 
walls  of  the  scrotum  from  before  backward  between  the  vas  deferens  and 
the  plexus  of  veins.  If  two  needles  are  on  hand,  the  one  now  passed 
through  should  be  left  in  position,  and  the  pressure  with  the  thumb  and 
finger  of  the  left  hand  being  no  longer  needed,  this  hand  may  be  used 
to  facilitate  the  second  step  in  the  operation.  The  second  needle,  with- 
out being  threaded,  should  now  be  made  to  enter  by  the  side  of  and  in 
the  same  opening  with  the  first,  and  as  soon  as  the  point  is  well  within 
the  dartos — but  not  deep  enough  to  puncture  the  veins — it  .should  be 
carefully  worked  between  the  veins  and  dartos,  around  the  mass  to  the 
outer  side,  and  made  to  emerge  behind  at  the  same  opening  with  the 
other  instrument.  The  thread  is  now  disengaged  from  the  first  needle 
and  carried  through  the  eye  of  the  second,  whicli,  ujjon  being  withdrawn, 
completes  the  circuit  of  the  ligature  around  the  mass.  It  should  now 
be  tied  slowly  and  securely.  The  single  knot  is  preferable,  since  the  fric- 
tion of  the  double  knot  is  so  great  that  the  thread  may  break  in  the 
effort  to  draw  it  tight  enough  to  constrict  the  veins  (an  accident  which 
has  twice  happened  to  myself).  The  first  needle  should  not  be  with- 
drawn until  the  ligature  is  secured,  since,  should  the  thread  break,  the 
second  needle  will  alone  have  to  be  inserted.  As  the  first  loop  of  the 
knot  is  tightened,  the  mass  within  its  grasp  slionld  be  held  by  an  assist- 
ant to  prevent  its  slipping  before  the  second  loop  is  finished.  When 
completed,  the  ends  are  cut  close  to  the  hole  of  entrance,  and  the  walls  of 
the  scrotum  separated  when  the  knot  and  ends  disappear  inside  the  dar- 
tos. A  light  sublimate  dressing  is  required.  The  patient  should  remain 
in  bed  one  day,  and  keep  quiet  about  the  hou.se  for  four  or  five  more. 


THE  VESICUL^  SEMINALES. 


671 


Little  or  no  pain  is  experienced  after  the  operation,  and  none  in  its  per- 
formanfp.  The  ligature  l)ecomes  encajisuled  and  remains  harmless.  In- 
flammation and  suppuration  are  scarcely  possible  where  the  antiseptic  de- 
tails are  proiaerly  carried  out.  The  tissues  around  and  below  the  thread 
are  indurated  within  a  few  hours,  and  remain  so  for  a  number  of  weeks, 
the  coagulated  blood  undergoing  gradual  absorption.  Recovery  follows 
in  a  large  proportion  of  cases.  Catgut  is  not  reliable  as  a  ligature  in 
this  operation,  on  account  of  the  danger  of  too  rapid  absorption.  In  one 
case  I  failed  with  this  material,  afterward  effecting  a  cure  vv-ith  silk, 
which  was  employed  at  the  suggestion  of  Prof.  Keyes. 

Second  Method — Ligature  tJirough  an  Open  Wound. — Anaesthetize 
the  patient,  shave  the  parts  thoroughly,  and  expose  the  cord  l)y  an  in- 
cision several  inches  in  length  made  alcjng  its  anterior  lateral  aspect. 
Search  for  the  vas  deferens,  which  can  be  easily  recognized  after  the  skin 
is  turned  aside,  by  its  cartilaginous  feel ;  have  this  held  to  one  side,  and, 
with  an  aneurism-needle  armed  with  good-sized  catgut  ligatures,  tie  the 
veins  separately.  In  performing  this  operation  it  is  advisable  to  leave 
one  good-sized  vein  to  convey  the  blood  back  from  the  testis,  and  to  tie 
the  others  in  several  places.  The  wound  should  be  closed  with  catgut, 
and  a  bone  drain  inserted.  As  stated  before,  this  operation  wiU  only  be 
justified  in  case  of  repeated  failure  by  the  former  procedure. 

In  very  exceptional  cases  the  scrotum  may  be  so  elongated  that  am- 
putation of  the  redundant  portion  is  necessitated  after  the  veins  are  tied. 


In  performing  this  operation  Henry's  clamp  (Fig.  663)  will  be  found 
of  great  service,  which,  if  properly  adjusted,  allows  the  amputation  to 
be  made  and  the  edges  of  the  wound  sewed  with  close  silk  sutures  while 
the  instrument  is  in  position,  thus  avoiding  all  haemorrhage  and  the 
necessity  for  a  single  ligature  in  the  line  of  amputation.  If  this  instru- 
ment can  not  be  obtained,  the  testicles  may  be  puslaed  up  into  the  rings 
and  the  amputation  effected  by  cutting  across  the  scrotum  below  the 
fingers  of  an  assistant  which,  by  grasping  the  tissues  properly,  control 
aU  bleeding. 

The  VesiculcB  Semiiinles  and  Vas  Deferens. — The  seminal  vesicles 
are  occasionally  wanting,  from  failure  of  development,  or  from  atrophy  as 
a  result  of  infiammation.  Wounds  of  these  organs  are  rare.  If  incised 
or  punctured,  temi)orary  fistula  may  result,  with  subsequent  atrophy. 
Inflammation  of  the  vesicuhe  seniinales  occasionally  occurs  by  exten- 


672  A  TEXT-BOOK   ON   SURGERY. 

sion  from  the  urethra  or  from  the  epididymis  and  vas  deferens,  or  with 
prostatitis  or  proctitis. 

Occlusion  of  the  ejarnlatory  duet  induces  over-distention  of  these 
organs.     Several  cases  of  calculus  of  the  duct  have  been  recorded. 

The  diagnosis  in  dilatation,  hypertrophy,  or  inflammation  of  these 
cysts  depends  upon  careful  rectal  exploration. 

The  vas  deferens  is  more  or  less  involved  iu  all  inflammator}'  ju-o- 
cesses  which  occur  in  the  epididymis.  It  is  also  subject  to  invasion  by 
iuflammation  from  the  urethra  and  i)rostate.  Tuberculosis  of  this  ves- 
sel may  follow  tuberculosis  of  the  testes  and  epididymis.  Lesions  of  this 
organ  require  no  especial  consideration. 

Epididijmis. — Neoplasms  of  the  sheath  of  the  spermatic  cord  are 
rare.  In  his  excellent  monograph,  Kocher  mentions  isolated  cases  of 
lipoma,  fibroma,  or  myxofibroma  and  sarcoma. 

Epididymitis  results  occasionally  from  direct  violence,  but  is  chiefly 
due  to  urethritis  and  the  extension  of  the  inflammatory  process  along 
the  vas  deferens.  Metastatic  or  "sympathetic"  inflammation  of  this 
organ  is  very  rare.  It  may  be  acute  or  chronic.  The  inflammatory  jn'o- 
cess  may  be  confined  to  the  epididymis  or  invade  the  testicle.  Acute 
epididymitis  always  involves  the  tunica  vaginalis  (with  which  it  is  in 
contact),  and  very  frequently  the  testicle.  Specific' urethritis  stands  first 
in  order  in  the  causation  of  epididymitis.  The  introduction  of  a  sound 
or  catheter,  the  lodgment  of  a  calculus  in  the  urethra  or  prostate,  strict- 
ure, cystitis,  and  prostatitis  may  also  cause  this  disease. 

The  symptoms  of  acute  epididymitis  are  a  sense  of  uneasiness  or 
pain,  varying  in  intensity  in  the  organ  affected,  or  in  the  cord  or  groin. 
It  is  increased  by  pressure,  when  the  erect  posture  is  assumed,  or  in 
walking. 

In  severe  cases  a  chill  or  rigors  occur,  followed  by  a  marked  rise  in 
temperature.  Upon  inspection  there  will  be  more  or  less  induration 
along  the  posterior  border  of  the  testicle,  with  heat,  redness,  and  ten- 
sion. The  testicle  is  more  or  less  enlarged,  and  very  frequently  there  is 
a  serous  transudation  into  the  cavity  of  the  tunica  vaginalis  testis. 

The  pathological  changes  consist  chiefly  of  hypersemia  and  infiltra- 
tion of  the  connective-tissue  framework  with  embryonic  cells.  The 
epithelial  lining  membrane  is  also  thickened  and  injected. 

The  diagnosis  depends  upon  the  symptoms  above  given.  The  prog- 
nosis is  usually  favorable.  One  attack,  however,  predisposes  to  another. 
In  some  instances  occlusion  of  the  efferent  apparatus  results  from  con- 
traction of  the  products  of  inflammation,  and  sterility  follows.  Sper- 
matic fistula  is  the  rule  in  these  cases. 

The  treatment  consists  in  the  administration  of  saline  laxatives  in 
order  to  empty  the  alimentary  canal.  The  patient  should  be  placed 
upon  his  back,  and  the  inflamed  organ  supported  by  either  a  three-cor- 
nered pillow  between  the  thighs,  or  a  towel  pinned  around  both  thighs 
just  below  the  base  of  the  scrotum.  Upon  this  a  small  bladder  filled 
with  crushed  ice  may  be  placed,  and  the  inflamed  organ  allowed  to  rest 
upon  it.     If  cold  is  not  grateful,  warm  cloths  or  a  poultice  may  be  sub- 


THE  TESTICLE.  673 

stitiited.     The  application  of  from  three  to  six  leeches  will  at  times 
relieve  the  local  congestion. 

Usually  rest  in  bed  will  alone  suffice  to  effect  a  cure.  In  some  in- 
stances operative  interference  is  indicated.  When  the  tension  is  great 
and  the  pain  extreme,  the  happiest  results  will  follow  multiple  jiuncture. 
Proceed  as  follows  :  Take  a  sharp,  narrow  knife  and  push  it  through  a 
cork  until  from  a  quarter  to  half  an  inch  of  the  point  is  exposed.  Hold 
the  organ  in  the  left  hand  so  as  to  ex^DOse  the  posterior  aspect  of  the 
epididymis  and  make  the  skin  fairly  tense,  and  plunge  the  blade  in  up  to 
the  cork  in  from  two  to  six  or  ten  points  along  the  most  swollen  and  in- 
durated portions  of  the  tumor.  A  free  escape  of  dark  blood  follows. 
The  operation  is  very  jiainful,  but  the  relief  is  marked  and  immediate. 
A  suspensory  bandage  should  be  worn  during  convalescence.  The  treat- 
ment of  chronic  epididymitis  will  be  considered  with  that  of  orchitis. 

The  Testicle. — Wounds  of  this  organ  do  not  demand  especial  consid- 
eration. Hernia  of  the  tubules  not  infrequently  occurs  from  incision  or 
puncture  of  the  tunica  albiiginea.  Reduction  is  practically  impossible. 
The  protruded  portion  should  be  tied  off  with  a  catgut  ligature,  the  ex- 
cess of  substance  beyond  the  thread  cut  oflf,  and  the  organ  returned  to 
the  noi'mal  position. 

Inflammation  of  the  testis  (orchitis)  may  result  from  direct  violence, 
from  the  extension  of  an  epididymitis,  or  from  metastasis.  Orchitis  is 
frequently  met  with  as  a  symptom  of  '*  mumps,"  but  the  relation  between 
these  two  processes  is  not  understood. 

The  si/mpfoms  are  enlargement  of  the  organ,  with  Y>^m  usually  in- 
tense. The  swelling  is  slow  on  account  of  the  great  resistance  offered 
by  the  tunica  albuginea.  The  skin  over  the  organ  is  tense  and  reddened, 
and  at  times  oedematous,  especially  when  an  epididymitis  precedes  the 
inflammatory  process  in  the  testicle. 

In  severe  cases  gangrene  may  ensue,  and  the  tunica  vaginalis  and 
scrotal  walls  may  become  involved.  In  mild  cases  the  ixdliological 
changes  are  chiefly  hyper?emia  and  the  formation  of  a  limited  amount  of 
embryonic  tissue  along  the  blood-vessels  and  in  the  connective-tissue 
septa  of  this  organ.  In  the  severer  forms  this  process  is  greatly  exag- 
gerated, and  as  a  result  of  the  extensive  hyperplasia  the  circulation  is 
aiTested,  and  death  of  the  tubular  structure  ensues.  Or,  if  gangrene 
does  not  occur,  atrophy  of  the  secretory  apparatus  follows  as  a  result 
of  contraction  of  the  products  of  inflammation.  In  some  instances  the 
swelling  subsides,  leaving  no  marked  changes  in  the  organ. 

The  prognosis  is  in  exact  relation  to  the  symptoms.  Slild  cases, 
especially  in  the  forms  occurring  with  urethral  epididymitis,  generally 
terminate  in  one  or  two  weeks  in  recovery  and  restoration  of  the  organ 
to  its  normal  condition.  In  cases  where  the  symptoms  are  severe  from 
the  start,  the  prognosis  is  grave  imless  early  relief  is  afforded,  and  even 
then  it  is  not  always  favorable. 

Treatment. — Rest  in  the  dorsal  decubitus  should  be  insisted  upon  in 
even  the  mildest  cases,  for  not  infrequently  dangerous  orchitis  is  pro- 
voked by  neglect  of  this  pi'ecaution. 

43 


674  A  TEXT-BOOK   ON   SURGERY. 

The  position  of  the  testicle  should  be  elevated,  as  in  epididymitis. 
The  local  application  of  cold  is  frrateful  and  advantageous  in  most  cases. 
The  organ  is,  however,  so  sensitive  that  no  pressure  is  tolerated.  This 
can  be  obviated  by  making  a  ring  of  cloths  wrapped  around  a  small 
hoop,  leaving  a  lumen  large  enough  to  include  the  scrotum  and  penis. 
The  ice-bag  is  laid  uihjii  this  ring,  which  prevents  any  pressure  upon  the 
inflamed  organ. 

When  the  effusion  is  rapid,  causing  dangerous  tension  of  the  fibrous 
cai)sule,  surgical  interference  is  imperative. 

The  operation  consists  in  seizing  the  organ  with  the  left  hand,  so  as 
to  render  it  steady  and  the  skin  tense,  puncturing  the  scrotum  and  pa- 
rietal layer  of  the  tunica  vaginalis  testis,  and  thus  subcutaiief)usly  making 
a  series  of  incisions  through  the  tunica  albuginea  on  its  anteriiu-  and 
antero-lateral  aspects.  The  incisions  should  be  about  half  an  inch  in 
length,  and  are  much  prefei'able  to  simple  puncture. 

The  danger  of  hernia  testis  does  not  contraindicate  this  procedure. 

Chronic  orchitis,  not  due  to  syphilis,  is  comparatively  rare.  When 
it  occurs,  it  usually  follows  an  acute  inflammation.  The  pathological 
change  consists  in  a  thickening  of  the  tunica  albuginea  and  of  the  con- 
nective-tissue septa.  Embryonic  cells,  collected  in  groups  or  nests,  in 
various  stages  of  development,  are  crowded  along  and  around  the  blood- 
vessels and  seminiferous  tubules,  as  well  as  scattered  about  in  the  inter- 
tubular  spaces.  As  the  process  continues,  the  tubules  disappear  under 
the  pressure  of  the  new  inflammation-tissue.  In  a  certain  proportion  of 
cases  cysts  form  in  the  following  manner :  The  peripheral  cells  of  one  or 
more  foci  of  the  embryonic  tissue  organize  into  connective  tissue  and  aid 
in  forming  the  investing  capsule.  The  cells  within  this  new  capsule  un- 
dergo granular  metamorphosis,  and  later  liquefaction,  by  absorption  of 
fluid  from  the  surrounding  vessels.  In  other  cases  foci  of  supimration 
(multiple  abscess  of  the  testicle)  may  remain  from  an  acute  inflammation 
and  be  present  in  chronic  orchitis  Icrag  after  the  acute  synii)toms  have 
subsided.  The  contents  of  these  foci  may  also  undergo  caseous  degen- 
eration. 

The  symptoms  of  chronic  orchitis  are  those  of  progressive  enlarge- 
ment of  this  organ.  In  some  instances  pain  is  wanting,  in  others  it  is 
present,  though  less  intense  than  in  the  acute  form,  while  in  a  third  cate- 
gory may  be  classed  cases  of  chronic  orchitis  with  intercurrent  attacks 
of  acute  inflammation  and  the  accompanying  exacerbations  of  pain. 
The  organ  varies  in  size  from  two  to  four  or  five  inches  in  its  greatest 
diameter.  Much  annoyance  is  occasioned  in  the  larger  tumors  by  the 
dragging  upon  the  cord. 

The  diagnosis  is  between  hydrocele  of  the  tunica  vaginalis,  inflam- 
mation of  the  walls  of  this  cavity,  with  exudation  and  thickening  and 
adhesion  to  the  testicle,  syphilitic  orchitis,  and  tuberculosis  testis.  Hy- 
drocele is  easily  excluded  by  fluctuation,  translucency,  and  aspiration. 
In  periorchitis  with  exudation  and  adhesions,  differentiation  will  at  times 
be  difficult.  The  obliteration  of  the  cavity  of  the  tunica  vaginalis  renders 
the  superficial  tissues  less  freely  movable  upon  the  body  of  the  testis. 


TUBERCULOSIS   OF  THE  TESTICLE.  675 

In  orchitis  the  surface  of  the  enlargement  is  smooth,  spherical,  and  of 
like  consistence  at  all  points  ;  often  in  periorchitis  ridges  of  new  tissue 
can  be  made  out ;  there  are  soft  spots  or  depressions  which  can  be  recog- 
nized by  careful  palpation. 

If  syi^hilitic  orchitis  is  suspected  (even  if  the  histoiy  of  this  disease  is 
denied),  it  will  be  advisable  to  administer  the  protoiodide  of  mercury  and 
the  iodide  of  potassium  for  several  weeks.  The  marked  diminution  of 
the  tumor  will  be  confirmatory  of  the  suspicion  of  the  syphilitic  dys- 
crasia.  The  extraordinary  weight  of  a  syphilitic  testicle  should  be  borne 
in  mind. 

Tuberculosis  testis  is  usually  preceded  by  the  deposit  of  tuberculous 
matter  in  the  epididymis.  Pain  in  this  affection  is  insignificant  and  en- 
tirely disproportionate  to  the  rapidity  of  the  infiltration  and  enlarge- 
ment. Moreover,  orchitis  and  epididymitis  may  usually  be  traced  to 
some  direct  and  exciting  cause  which  is  absent  in  tubercular  disease. 

The  indications  in  treatment  are,  first  of  all,  to  remove  every  cause 
of  irritation,  to  keep  up  the  tone  of  the  system  by  judicious  feeding 
and  medication,  and  to  support  the  heavy  organ  by  suspension.  When 
these  measures  fail  to  arrest  the  disease,  or  when  the  pain  becomes  so 
gi'eat  that  the  patient's  comfort  is  interfered  with,  or  when  the  disinte- 
gration of  the  organ  is  threatened,  castration  may  be  entertained.  Be- 
fore carrying  out  such  an  extreme  measure,  the  precaution  should  be 
taken  to  explore  the  organ  through  an  incision  in  the  scrotum,  in  order 
to  determine  its  exact  condition  before  removing  it. 

Tuhercidosis  of  the  Testicle  and  Epididymis. — True  miliary  tuber- 
culosis of  the  testicle  and  epididymis  is  comparatively  rare.  Many  cases 
which  have  been  recorded  as  tuberculosis  must,  upon  analysis,  be  classed 
with  a  non-tubercular  inflammation,  the  embryonic  tissue  of  which  has 
undergone  caseous  degeneration. 

Tubercular  disease  of  the  testicle  alone  is  the  exception.  The  epi- 
didymis is  usually  first  invaded,  and  from  this  point  the  new  tissue 
spreads  into  the  testicle,  and  not  infrequently  along  the  vas  deferens  to 
the  seminal  vesicles,  as  well  as  to  the  tunica  funiculi  and  tunica  vagi- 
nalis testis. 

While  it  may  be  slow  in  some  instances,  as  a  rule  the  invasion  is 
rapid,  occupying  from  two  to  eight  weeks  in  a  general  infiltration  of 
both  organs.  The  symptoms  are,  upon  the  whole,  obscure.  One  point 
of  great  diagnostic  value  is  that  the  pain  is  entirely  disproportionate  to 
the  rapidity  and  extent  of  the  tumefaction.  In  simple  orchitis  and  epi- 
didymitis, pain  is  extreme  and  pressure  unbearable.  In  tubereidar  or- 
chitis pain  is,  as  a  rule,  slight,  and  may  not  be  present  at  all.  In  a 
certain  proportion  of  cases  there  aatII  be  sudden  and  recurring  exacer- 
bations of  pain,  indicating  a  circumscribed  acute  orchitis,  the  result  of 
irritation  from  the  presence  of  the  cell-elements  of  the  tubercular  pro- 
cess. Ulceration  and  the  formation  of  fistulae  occur  in  a  certain  propor- 
tion of  cases. 

In  simple  orchitis  and  epididymitis,  the  cord  is  not  involved,  while 
not  infi-equently  in  tuberculosis  the  deposit  rapidly  travels  along  the 


676  A  TEXT-BOOK  OX  SURGERY, 

vas  deferens.  Grasped  between  tlie  fingers,  the  tubercular  organ  is  felt 
to  be  hard,  and  its  surface  uneven  and  nodular. 

The  initial  morbid  change  is  the  deposit  around  the  seminiferous 
tubes  of  clusters  or  nests  of  lymphoid  cells.  Within  the  tubes  the  endo- 
thelia  are  thickened  and  undergoing  granular  or  caseous  metamorphosis. 
Later,  the  connective-tissue  septa  become  infiltrated  with  the  new  cells. 
The  process  ends  in  compression  and  destruction  more  or  less  complete  of 
the  tubules.  The  centers  of  these  clusters  of  cells  farthest  removed  from 
the  vascular  network  undergo  granular  or  caseous  metamorphosis,  form- 
ing at  times  cyst-like  caverns,  or  at  other  times  abscesses  and  listulaj. 

Treatment. — The  prognosis  of  tubercular  disease  of  these  organs  is 
so  gi'ave  that  when  an  early  diagnosis  can  be  made  out,  extirpaticm  of 
the  diseased  tissues  should  be  considered.  If  only  one  side  is  involved, 
and  the  other  organ  is  fully  developed,  there  should  be  no  hesitation  in 
advising  tlie  operation  of  castration. 

When  tlie  diagnosis  is  doubtful,  it  will  be  wise  to  keep  the  patient 
under  constant  observation,  with  especial  regard  to  the  advance  of  the 
disease  along  the  cord,  and  when  this  is  evident,  and  when  there  is  no 
positive  evidence  of  tubercular  deposits  elsewhere,  extirpation  is  indi- 
cated in  order  to  prevent  invasion  of  the  prostate  and  general  dissemi- 
nation. When  both  organs  are  involved,  the  question  of  complete  cas- 
tration is  one  of  doubtful  propriety. 

EncTiondroma  of  the  testicle  is  not  altogether  infrequent.  It  occurs 
most  often  after  injury.  While  it  is  prone  to  originate  in  the  organ,  it 
may  spread  from  the  epididymis  to  the  testicle.  The  volume  of  the  organ 
varies,  at  times  reaching  a  large  size.  Enchondroma  testis,  as  with  al- 
most all  forms  of  neoplasm  seated  in  this  structure,  is  apt  to  undergo 
cystic  degeneration. 

The  diagnosis  must  be  based  upon  the  hard,  elastic  feel  peculiar  to 
this  form  of  tumor. 

The  treatment  is  either  expectant  or  operative,  as  circumstances  may 
demand.  Castration  is  indicated  when  the  disease  is  unilateral,  and 
when  the  size  of  the  tumor  is  such  that  the  function  of  the  opposite  organ 
is  threatened. 

Adenoma  testis  occurs  chiefly  from  the  twentieth  to  the  fortieth  year 
of  life.     It  has  so  far  not  been  observed  during  childhood. 

The  development  of  the  tumor  is  usually  rapid,  attaining  a  diameter 
of  three  or  four  inches  or  more.  Only  one  organ  is  usually  affected. 
Pain  is  not  a  prominent  symptom  in  the  earlier  history  of  this  neo- 
plasm, biit,  after  the  growth  attains  a  sufficient  bulk,  it  causes  more  or 
less  pain  by  pressure  and  weight.  To  the  touch  it  is  soft  and  compres- 
sible. The  formation  of  cysts  in  various  portions  of  the  neoplasm  is 
frequent  (cysto-adenoma)  (Fig.  664). 

Under  the  microscope  the  epithelia  of  the  seminiferous  tubules  are 
seen  to  be  swollen,  while  their  caliber  is  more  or  less  completely  occluded 
with  the  round  cells  of  the  new  (adenoid)  tissue. 

The  prognosis  is  not  favorable,  and  the  diagnosis  difficult.  Since  the 
function  of  the  organ  is  wholly  impaii-ed,  and  since  the  rapid  develop- 


CARCINOMA— SARCOMA  TESTIS. 


677 


ment  of  the  tumor  is  of  itself  an  indication  of  the  gravity  of  the  lesion, 
the  matter  of  exact  recognition  of  adenoma  is  not  important.  In  all  of 
these  rapid  and  threatening  neoplasms,  especially  when  a  single  testicle 

or  epididymis  is  involved,  the  safest 
course  is  in  early  and  prompt  ex- 
cision. 

Garcinoma. — Both  scirrhus  and 
medullary  cancer  may  develop  pri- 
marily in  the  testicle  or  epididymis. 
The  encephaloid  variety  is  most  fre- 
quently encountered.  The  micro- 
scopical characters  of  these  different 
varieties  of  cancer  will  be  given  in 
the  chapter  on  tumors. 

Carcinoma  of  the  testis  is  apt  to 
occur  about  the  age  of  puberty,  al- 
though it  may  be  met  with  later  in 
life.  One  organ  is  affected  as  a  rule. 
It  is  more  apt  to  begin  in  the  tes- 
ticle than  in  the  epididymis.  In  the 
early  stages  of  the  development  can- 
cer of  the  testes  is  not  painful,  but 
as  the  disease  advances  the  suffer- 
ing may  be  intense.  Early  removal 
offers  the  only  hope  of  cure,  and 
this,  unfortunately,  is  not  great. 
Sarcoma  testis  occurs  at  all  ages,  but  is  chiefly  confined  to  childhood 
and  eai-ly  manhood.  Following  the  general  law  of  sarcomata,  that  of 
the  testicle  is  rapid  in  growth,  attaining  at  times  an  enormous  size.  This 
is  one  of  the  chief  diagnostic  points  of  this  tumor,  which  is  hard,  usually 
liyriform  in  shape,  and  of  comparatively  smooth  contour.  Castration 
offers  the  only  hope  of  relief. 

It  will  be  seen  from  the  foregoing  that  accurate  diagnosis  of  the  va- 
rious neoplasms  which  develop  in  the  testicle  is  difficult  and  often  im- 
possible. Almost  all  of  these  moi'bid  processes  lead  to  destruction  of 
the  oi'gan  and  loss  of  function,  and  immediately  or  remotely  threaten 
the  life  of  the  individual. 

Thus  tuberculosis,  adenoma,  carcinoma,  and  sarcoma  may  be  classed 
as  malignant.  Enchondroma,  although  not  intrinsically  malignant,  leads 
to  loss  of  function,  and  in  this  particular  justifies  operative  interference. 
The  same  applies  with  greater  force  to  cystic  degeneration  of  this  organ, 
since  cysts  often  develop  in  malignant  neoplasms  of  the  testicle.  In  view 
of  these  facts,  when  only  a  single  organ  is  involved,  it  will  be  advisable 
in  the  early  history  of  any  neoplasm  of  this  organ  to  consider  the  pro- 
priety of  castrati(m. 

The  operation  is  thus  performed  :  Shave  the  scrotum  and  pubes,  and 
make  an  incision  extending  from  tlie  external  abdominal  ring  along  the 
anterior  surface  of  the  cord  and  testicle  to  the  base  of  the  scrotum. 


Fio.  664. — Cystic  degeneration  cf  iidenoma  of  tiie 
testicle  (cysto-adenoma).    (Alter  Kocber.) 


678  A  TEXT-BOOK  ON  SURGERY. 

When  the  morbid  process  involves  tlie  serotal  tissues,  and  even  when 
there  is  a  suspicion  of  involvement,  the  primary  incision  should  be  car- 
ried well  away  from  the  suspected  tissue  into  the  healthy  structures. 

Two  points  of  importance  are  suggested  in  the  removal  of  this  organ. 
The  first  is  to  make  an  incision  into  the  mass  in  order  to  clear  up  the 
diagnosis;  the  second  is  to  secure  the  vessels  by  the  ligature  ai)])lied 
near  the  external  ring,  and  thus  prevent  the  danger  of  forcing  septic  or 
metastatic  matter  in  the  lymph  channels  or  vessels  leading  toward  the 
center.  The  cord  should  be  exposed  at  the  ring,  the  vas  deferens  iso- 
lated, and  a  large,  double  catgut  ligature  thrown  around  so  as  to  in(;lude 
the  entire  cord  except  tlie  vas  deferens.  This  is  twisted  around  the  cord 
while  the  exploratory  incision  is  being  made,  and,  if  the  diagnosis  is 
confirmed,  the  catgut  is  tied  and  the  cord  divided  betw^een  the  two  liga- 
tures. The  diseased  organ  is  then  dissected  out,  the  hjemorrhage  ar- 
rested, a  drainage-tube  introduced,  and  the  wound  clo.sed  with  catgut 
sutures.  A  single  dressing  will  usually  suffice.  When  the  vas  deferens 
is  divided,  the  accompanying  artery  will  have  to  be  separately  tied. 

Malposition. — One  or  both  of  these  organs  may  be  absent  from  the 
normal  position  in  the  scrotal  sac.  The  descent  from  the  abdominal 
cavity  may  be  prevented  by  narrowing  or  closure  of  the  inguinal  rings, 
or  the  inner  ring  may  be  passed,  the  testicle  being  arrested  at  the  outer 
opening,  and  thus  imprisoned  in  the  canal ;  or,  passing  both  rings,  it 
may  lodge  beneath  the  skin  near  the  pubic  crest,  or  in  the  perin;euni  or 
groin.  Occasionally  the  testicle  remains  entirely  within  the  abdominal 
cavity.  Another  rare  form  of  malposition  is  when  the  organ  is  turned 
obliquely  or  crosswise  in  the  scrotum. 

Misplaced  testicle  does  not  usually  give  rise  to  great  inconvenience 
until  the  approach  of  puberty,  when  its  normal  development  is  inter- 
fered with  by  compression.  If  it  is  lodged  in  the  inguinal  canal,  where 
it  is  acted  upon  by  muscular  contraction,  it  may  cause  pain  at  an  earlier 
period.  The  descent  of  a  hernia  upcm  a  testicle  thus  imprisoned  gives 
rise  to  considerable  annoyance.  An  imprisoned  testicle  is  occasionally 
the  seat  of  a  neoplasm.  The  symptoms  are  those  of  pain,  neuralgic  in 
character,  and  the  diagnosis  must  depend  upon  the  absence  of  the  organ 
from  its  normal  place  and  its  recognition  in  the  position  of  the  abnormal 
swelling. 

Misplaced  testicle  requires  no  special  treatment  until  it  becomes  a 
source  of  inconvenience  or  annoyance,  or  is  the  seat  of  some  new  forma- 
tion.    Extu'pation  is  then  demanded. 

Supernumerary  testicle  does  not  occur.  In  several  instances  a  cyst  or 
other  neoplasm  has  been  mistaken  for  an  extra  organ. 

Diseases   of  the  Female  Organs  of  Generation  demanding 

Abdominal  Section. 

Hysterotomy  and  Hysterectomy.— Hysterotomy.,  or  cutting  into  the 
uterus  for  the  extraction  of  the  foetus  from  the  living  mother,  is  an  op- 
eration which  has  been  greatly  perfected  within  the  last  few  years, 


HYSTEROTOMY.  679 

chiefly  owing  to  the  labors  of  Saenger  and  Leopold.  It  is  indicated  when 
at  full  term,  labor  having  begun,  it  is  found  impossible,  on  account  of 
insurmountable  disproportion  between  the  diameters  of  the  pelvic  outlet 
and  the  child,  to  effect  delivery  by  the  vagina.  AVhen  this  condition  is 
evident,  proceed  as  rapidly  as  possible  in  the  following  manner : 

If  the  membranes  are  not  already  ruptured,  break  them.  Disinfect 
the  vagina  and  genitals  with  sublimate  solution,  1  to  3500.  Prepare  the 
abdomen  as  for  an  ovariotomy,  and  make  a  long  abdominal  incision, 
controlling  all  bleeding  with  catgut  ligatures  as  the  operation  proceeds. 
Having  entered  the  abdominal  cavity  and  made  the  opening  large 
enough,  place  three  or  four  silk  sutures  at  the  upper  end  of  the  wound 
in  order  to  narrow  the  opening  as  soon  as  the  uterus  is  drawn  out  of 
the  incision,  thus  avoiding  extrusion  of  the  intestines.  Drag  the  uterus 
outside  the  abdominal  cavity,  and  close  the  upper  portion  of  the  wound 
by  tightening  the  sutures  already  in  position.  If  the  intestines  should 
be  protruded,  protect  them  with  warm  towels  wrung  out  of  Thiersch's 
solution,  and  beneath  the  uterus  pass  a  piece  of  rubber  cloth,  disinfected 
in  the  same  solution,  to  protect  the  abdominal  cavity  from  the  entrance 
of  blood.  Around  the  cervix  uteri  pass  a  stout  piece  of  elastic  tubing, 
and  draw  it  tight.  Immediately  incise  the  uterus  in  the  median  line 
and  in  its  long  axis,  limiting  the  incision  below  to  the  peritoneal  reflec- 
tion, thus  avoiding  the  large  circular  sinuses  about  the  os  internum,  and 
extending  it  upward  if  necessary.  Remove  the  cliild,  and  hand  it  to  an 
assistant  to  resuscitate.  The  uterus  will  now  usually  contract.  Intro- 
duce the  hand  into  the  uterus  and  remove  the  placenta.  The  uterine 
cavity  is  to  be  next  disinfected  with  a  l-to-5000  sublimate  solution.  Un- 
less the  cervical  canal  is  widely  dilated  (and  this  should  be  ascertained 
before  the  operation),  the  use  of  a  iitero-vaginal  drainage-tube  is  indi- 
cated, and  this  latter  must  be  of  stifl'  rubber.  The  next  step  in  the 
operation  is  the  insertion  of  the  sutures  in  the  wall  of  the  uterus.  First 
ascertain  whether  the  peritoneal  covering  of  this  organ  is  sufficiently 


Mucosa. 


Fio.  665. — Sutures  in  Cscsnrcan  section.  Method  of  passing  tlie  sutures  in  closin?  tlie  wall  of  the  uterus 
after  hy^terotomy.  «,  The  prritoni'al  coverini.'  ilissected  up  alon<r  the  ed^'e  of  the  incision  and  in- 
verted by  till!  catgut  suture,  alter  the  method  of  Lerahert.  4,  The  museuhir  substance,  with  the 
silver-wire  suture  passed  through,     c,  Decidiia.     (Drawn  by  Dr.  W.  R.  Pryor.) 

movable  to  allow  it  to  be  folded  in  between  the  sides  of  the  incision. 
If  need  be,  dissect  it  up  from  its  attachment  to  the  muscular  fibers  a 
slight  distance.     The  peritomeum  is  next  folded  in  between  the  lips  of 


680  A  TEXT-BOOK  ON  SURGERY. 

the  wound,  and  the  deep  satiires  are  passed  (Fig.  665).  These  should 
be  of  silver  wire,  because  they  are  cleaner  and  hold  more  unj'ieldingly 
than  silk.  They  should  be  close  enough  to  control  hsemorrhage  and 
secure  accurate  adjustment  of  the  sides  of  the  wound.  They  should 
6nter  the  peritoneal  covering  about  half  an  inch  from  the  edge  of  the 
wound,  and  pass  through  it  and  the  muscular  wall  to  the  decidna, 
which  must  not  be  included  in  the  suture  ;  then  across  to  the  other  side 
through  the  muscular  and  serous  coats.  After  twisting  the  silver  su- 
tures, the  superficial  sutures  of  fine  silk  are  introduced.  These  are  to 
be  from  twenty  to  thirty  in  number,  and  are  employed  to  secure  perfect 
coaptation  of  the  serous  edges  of  the  incision.  They  are  introduced  in 
the  same  way  as  Lembert's  suture  of  the  intestine.  Lastly  the  twisted 
silver  wires  are  cut  off  about  one-half  inch  from  the  level  of  the  incision 
in  the  uterus,  and  the  ends  turned  down  parallel  with  the  surface  of  this 
organ. 

The  incision  in  the  abdominal  wall  is  closed,  as  after  ovariotomy. 
There  are  certain  conditions  which  can  only  be  determined  by  inspec- 
tion through  the  incision  in  the  abdominal  wall  which  may  contraindi- 
cate  the  operation  just  given,  and  necessitate  a  modified  procedure. 

If  the  patient  has  been  long  in  labor,  and  considerable  time  has 
elapsed  after  the  membranes  have  ruptured ;  if  there  is  a  putrid  dis- 
charge from  the  vagina ;  if  the  symptoms  of  septic  fever  are  present, 
with  the  perimetrium  dulled  and  adherent  to  the  muscular  wall  of  the 
utems,  Porro's  operation — amputation  of  the  uterus  at  the  os  internum — 
is  indicated.  If  malignant  disease  of  the  cer\-ix  is  present,  Freund's 
operation  is  to  be  preferred.  If  the  pregnant-  utei-us  be  the  seat  of  a 
fibro-myoma,  and  so  situated  as  to  render  delivery  impossible,  or  if  a 
rupture  of  the  walls  of  the  uterus  has  occurred,  which  is  so  ragged  in 
outline  that  it  can  not  be  sutured,  Porro's  operation  is  indicated.  The 
objects  aimed  at  in  all  operations  for  the  artificial  delivery  of  children 
at  term  are,  preservation  of  the  mother's  life  and  future  health,  with, 
if  possible,  the  non-mutUation  of  her  generative  organs  and  the  delivery 
of  a  living  child.* 

Porro's  Operation  \ — ID/Hterectomy  during  Pregnancy. — The  abdom- 
inal incision  is  similar  to  that  just  given.  It  must  not  be  overlooked  that 
the  bladder  is  high  up  and  in  good  part  uncovered  by  the  peritonseum. 
As  soon  as  the  uterus  is  exposed  it  should  be  drawn  out  of  the  abdomen. 
Place  around  the  cervix  a  large  piece  of  rubber  tubing  if  an  ecraseur  or 
clamp  is  to  be  used ;  or  a  rubber  ligature,  if  that  is  to  be  permanent.  Pro- 
tect the  intestines  with  warm  towels  wet  in  Thiersch's  solution.  Under 
the  uterus  and  over  the  abdominal  incision  spread  a  large  piece  of  rubber' 
cloth,  protecting  the  peritoneal  cavity  from  the  entrance  into  it  of  blood, 
etc.  Tighten  the  rubber  ligature  around  the  cervix,  and  immediately  in- 
cise the  uterus  and  rapidly  extract  the  child.  The  incision  in  the  utems 
may  be  made  in  any  direction  convenient.     The  next  step  is  to  cut  off 

*  As  regards  statistics,  Saenger  gives  thirty  Cfesarenn  sections  performed  aa  above  de- 
scribed, with  a  mortality  of  26'7  per  cent. 

t  The  mort.ility  after  this  operation  is  greater  than  that  after  hysterotomy. 


HYSTERECTOMY.  681 

the  uterus  close  to  the  ligature.  Curette  out  the  cervical  canal,  or  burn 
it  and  the  stiimii  with  the  cautery.  Cleanse  the  peritoneal  sac  of  blood 
and  serum.  See  that  no  blood  has  collected  between  the  cervix  and 
pubes.  Transfix  the  stump  with  long  steel  pins  just  above  the  ligature, 
and  otherwise  treat  the  stump  as  should  be  done  after  hysterectomy  for 
fibro  myomata.  The  di-ainage-tube  (see  Fig.  6C7j  should  be  employed  in 
all  these  cases,  as  a  guarantee  against  peritonitis  and  sepsis.  The  stump 
should  be  dusted  with  iodoform,  as  heretofore  directed. 

Freund's  Operation. — Removal  of  the  uterus  for  malignant  disease 
of  this  organ  is  thus  performed  :  The  patient  is  prepared  as  for  an  ovari- 
otomy. The  vagina  is  cleansed  and  rendered  aseptic.  The  abdomen  is 
opened,  the  uterus  found  and  drawn  up  to  the  incision.  It  is  then  pulled 
to  one  side  and  the  broad  ligament  of  the  opposite  side  ligated  in  such  a 
way  that  the  ovarian  artery,  Fallopian  tube,  and  round  ligament  are  in- 
cluded in  the  grasp  of  the  ligature.  The  ligament  of  the  other  side  is  in 
the  same  way  tied  off.  The  uterine  arteries  are  next  deligated  by  means 
of  a  ligature  passed  through  the  fornix  vaginge.  If  it  be  desired  to 
remove  the  entire  organ,  the  bladder  is  separated  from  the  cervix,  and 
the  tissues  around  the  cervix  are  cut  through.  Freund  originally  left 
the  ligatures  long,  and  brought  them  out  of  the  vaginal  opening.  If  it  is 
desired  to  make  a  stump  of  the  cervix,  as  in  the  case  of  cancer  of  the 
fundus  uteri,  the  uterus  is  cut  off  just  above  the  utero-vaginal  junction, 
the  two  lips  of  the  cervix  brought  together  with  deep  sutures,  the  peri- 
tonaeum carefully  adjusted  over  them,  the  ligatures  cut  short,  and  the 
peritoneal  cavity  closed. 

Hysterectomy  for  the  Removal  of  Fibro-myomata — Schroeder\s  Op- 
eration.—Aitev  opening  the  abdomen  the  uterus  and  fibroids  are  freed 
from  adhesions.  A  temporary  elastic  ligature  is  tied  around  the  cenix, 
and  the  tumors  and  uterus  cut  away,  leaving  the  stump  in  the  shape  of 
a  V.  The  blood-vessels  are  now  ligated  with  catgut  {Schroeder  does  not 
insist  upon  this),  and  the  sides  of  the  cone  brought  together  by  layers  of 
close  sutures  which  begin  at  the  bottom  of  the  cavity.  This  mode  of 
suturing  is  continued  until  the  top  is  reached,  when  the  peritonaeum  is 
carefully  adjusted  over  the  stumj^  and  the  elastic  ligature  removed.  Or 
the  pedicle  may,  if  small,  be  transfixed,  ligated,  and  dropped.  The 
peritonseum  is  cleansed  of  blood,  etc.,  and  the  abdomen  closed.  If  the 
myoma  is  pedunciilated  and  the  uterus  itself  is  not  the  seat  of  multiple 
growths,  the  tumor  is  cut  off,  and  the  suturing  done  at  the  point  where 
the  tumor  grew.  Or,  if  the  tumor  is  sessile,  so  that  the  elastic  ligature 
can  not  be  employed,  it  is  advised  to  incise  the  capsule,  enucleate  the 
tumor,  and  bring  the  flaps  together  as  above  directed.  Keith  and  Hegar 
have  the  smallest  mortality  after  hysterectomy,  and  it  is  their  custom  to 
treat  the  pedicle  by  the  extra-peritoneal  method.  But  there  are  tumors 
which  can  not  be  so  treated  ;  these  Schroeder  enucleates  as  described. 

Hysterectomy  for  Fihro-myoma  ;  the  Stump  being  brouyht  ovt  at  the 
Wound  and  attached  thi're. — After  the  organ  is  exposed  and  all  adhe- 
sions tied  with  double  ligatures  and  divided  between  these,  or  broken 
loose  where  the  double  ligature  can  not  be  utilized,    the  elastic  liga- 


682  A  TEXT-BOOK  ON  SURGERY. 

ture  should  be  thrown  around  the  uterus  at  the  cervix,  the  rubber  pass- 
ing under  the  ovaries  and  compressing  the  broad  ligament  against  the 
cervix.  This  ligature  is  di-awn  tight  and  tied,  the  second  part  of  the 
knot  being  over  a  coarse  silk  tliread.  ^Vhen  the  last  knot  of  the  elastic 
ligature  is  made,  the  silk  thread  is  tied  around  this  to  prevent  slipping. 

Tlio  filu-oid  is  then  held  ui>  and  cut  off  above  the  elastic  ligature. 
The  stump  is  next  grasped  by  strong  forceps  and  trimmed.  Sutures  are 
then  passed,  first  through  the  parietal  peritonaeum  near  the  incision  and 
then  tlirough  the  stump  below  the  ligature,  in  such  a  way  that  when 
drawn  tight  the  lower  part  of  the  incision  will  surround  tlie  stump  just 
below  the  ligature,  with  the  peritoneal  surface  of  the  incision  fastened  to 
that  of  the  stump.  Steel  pins  or  skewers  should  be  passed  thi'ough  the 
stump  above  the  ligature.  The  sutures  around  the  stump  are  then  drawn 
tight,  the  wound  closed  as  after  ovai-iotomy,  the  stump  dusted  fi-eely 
with  iodoform,  and  the  dressing  applied.  The  indications  for  pelvic 
drainage  will  be  the  same  as  after  an  ovariotomj'.  The  cervical  canal  in 
the  stump  should  be  curetted  before  passing  the  steel  pins  ;  otherwise,  a 
fistulous  opening  may  persist  through  the  vagina,  uterine  stump,  and 
the  line  of  incision.  Frequently  the  fibroid  is  attached  to  the  unen- 
larged  uterus,  and  has  a  narrow  pedicle.  In  such  a  case,  the  uterus  and 
appendages  are  left,  and  the  new  growth  removed,  forming  the  stump 
where  the  tumor  joined  the  uterus. 

Surgical  Diseases  of  the  Fallopian  Tubes — Salpingitis. — Inflamma- 
tion of  the  Fallopian  tubes  may  demand  surgical  interference  when  peri- 
tonitis is  precii^itated,  or  when  from  occlusicm  of  one  or  both  outlets  of 
this  organ  the  products  of  intiammation  are  retained,  and  the  tube  is  dis- 
tended, forming  a  cyst-like  tumor. 

The  most  prominent  symptom  of  salpingitis  is  pain.  When  peritoni- 
tis does  not  exist,  it  is  confined  to  the  affected  side.  It  is  usually  con- 
tinuous, with  exacerbations  of  severity,  which  are  especially  marked  just 
before,  during,  and  after  the  menstrual  flow.  In  some  instances,  when 
the  flow  is  established,  the  suffering  is  less  intense.  The  menstrual  dis- 
charge is,  as  a  rule,  increased  in  quantity.  Salpingitis,  in  the  vast 
majority  of  cases,  results  from  the  direct  extension  of  some  inflamma- 
tory process  from  the  uterus.  Endometritis  or  metritis  following  gonor- 
rhcea,  abortion,  noi-mal  parturition,  or  that  resulting  from  a  chronic  in- 
flamnuition  due  to  malposition  of  this  organ  or  other  cause,  are  the  chief 
conditions  which  precede  this  affection. 

By  direct  j^alpation  over  the  abdomen  of  the  affected  side,  it  will  be 
seen  that  the  muscles  of  this  side  are  abnormally  tense,  and  that  acute 
pain  is  present  confined  to  a  limited  and  well-marked  area,  which 
corresponds  to  the  normal  position  of  the  tube.  In  the  vagina,  a  leu- 
corrhoeal  discharge  is  usually  observed,  and  diligent  examination  will 
reveal  great  tenderness  near  the  cervix,  upon  the  side  involved.  The 
uterus  may  be  normally  situated,  but  is  laterally  displaced  when  the 
tumor  is  at  all  large.  With  bimanual  examination,  often  necessary  under 
ether,  there  will  be  found  an  elastic,  if  not  fluctuating,  tumor,  s])ringing 
from  one  or  the  other  uterine  cornu,  and  directly  attached  to  the  uterus ; 


SALPINGITIS.  683 

perhaps  bulging  into  ttie  vagina  ;  sausage- shaped  when  moderately  large, 
but  round  when  as  large  as  an  orange  ;  often  movable,  but  almost  always 
with  false  attachments.  This  tumor  may  be  but  a  part  of  a  general  inflam- 
matory mass  filling  up  the  pelvic  cavity  and  rendering  fluctuation  hard 
to  obtain.  In  such  a  case,  the  uterus  is  fixed  to  this  mass.  As  a  rule, 
the  tube  is  prolapsed,  and  drags  with  it  the  ovary,  the  latter  l)eing  exter- 
nal to  and  above  the  cyst.  In  many  cases  the  diagnosis  is  easy,  but  in 
others  it  is  difficult. 

Treatment. — When  the  diagnosis  is  satisfactorily  determined,  and 
the  symptoms  are  urgent,  removal  by  abdominal  section  is  indicated. 
The  preparation  of  the  patient  and  for  the  operation  are  the  same  as  for 
ovariotomy.  When  the  peritonseum  is  opened,  the  tumor  may  be  dis- 
tinctly felt,  and  should  be  removed  without  rupture  of  the  cyst-wall 
when  this  is  possible.  Adhesions  to  the  neighboring  organs  will  be  found 
to  exist,  in  a  varying  degree,  in  all  cases.  Some  of  these,  which  are  vas- 
cular and  of  good  size,  require  to  be  tied  with  double  large-sized  catgut 
ligatures  and  divided,  while  others  may  be  torn  off.  The  silk  ligature 
should  be  passed  around  the  tube,  close  to  the  surface  of  the  uterus,  tied, 
and  the  mass  removed.  The  stump  beyond  the  ligature  should  be  care- 
fully disinfected  and  seared  with  the  actual  cautery.  If  rupture  should 
occur,  or  if  there  is  a  considerable  amount  of  oozing,  the  Sims's  drainage- 
tube  should  be  used. 

The  Ovaries. — Removal  of  the  ovaries  may  be  necessitated  on  account 
of — 1,  cystic  degeneration  ;  2,  cirrhosis  ;  3,  abscess  ;  4,  cystic,  and  5,  solid 
tumors. 

In  cystic  degeneration  the  ovary  is  enlarged,  and  the  interior  of  the 
organ  is  filled  with  small  cysts  wdth  dense,  fibrous  capsules.  They  can 
in  some  cases  be  seen  through  the  investing  membrane,  and,  if  punct- 
ured, will  give  exit  to  a  fluid  usually  clear,  but  at  times  brown,  or  even 
decidedly  stained  with  blood.  The  tumor  is  elastic  to  the  touch,  usually 
spherical,  and  rarely  attaining  as  much  as  a  diameter  of  two  inches. 
The  fimbriated  extremity  of  the  Fallopian  tube  is  often  adherent  to  the 
diseased  ovary.  In  rare  instances  the  broad  ligament  and  tube  may 
surroiind  the  cystic  tumor.  The  left  organ  is  affected  more  frequently 
than  the  right,  for  the  same  reasons  as  given  for  the  more  frequent  oc- 
currence of  varicocele  in  the  left  scrotum  (see  Varicocele).  The  pa- 
thology of  this  affection  is  not  yet  definitely  settled. 

In  cirrhosis  the  ovaries  are  usually  small,  and  have  a  furrowed  or 
withered  appearance  ;  occasionally  they  are  found  normal  in  size,  or  even 
slightly  enlarged.  The  normal  Graafian  follicles  are  entii-ely  destroyed 
in  well-marked  cases. 

In  more  recent  cirrhotic  disease  of  these  organs  the  cavities  of  the 
follicles  are  distended  with  a  bloody  fluid.  This  condition  is  almost 
always  due  to  a  connective-tissue  hyperplasia,  resulting  from  a  subacute 
inflammatory  process  in  the  ovary. 

In  abscess  of  this  organ  it  is  enlarged,  and  may  contain  one  cavity  or 
several  separate  collections  of  pus.  When  the  abscesses  are  small  and 
multiple,  the  gross  appearances  of  the  organ  are  not  unlike  those  of  an 


684  A  TEXT-BOOK  ON  SURGERY, 

ovary  with  cystic  degeneration.  Suppurating  salpingitis  (or  pyo-salpinx) 
may  be  present  with  abscess  of  the  ovary,  and,  in  rare  instances,  by 
reason  of  fusion  and  rupture  of  the  contiguous  walls,  there  results  a 
large  single  abscess.  Multiple  extravasation  of  blood  may  occur  in  ab- 
scess of  this  organ.  If  not  relieved  by  operation,  the  pus  may  eventually 
find  an  exit  thi-ough  the  vagina,  bladder,  or  intestine.  Adhesions,  as  a 
rule,  occur  between  the  ovary  and  one  or  more  of  the  contiguous  organs, 
or  to  the  pelvic  fascia. 

Symptoms. — In  ei/stic  degeneration  and  cirr/wsls;  dj'smenorrhoea  is 
the  most  prominent  symptom.  It  is  more- severe  with  the  former,  but  is 
severe  in  the  cirrhotic  ovary.  The  pain  usually  precedes  the  menstrual 
flow  from  a  few  hours  to  several  days,  and  in  extreme  cases  may  continue 
from  one  period  to  the  next.  It  is  usually  referred  to  the  groin  of  the 
affected  side,  and  thence  the  painfiil  sensations  may  radiate  over  the  abdo- 
men and  down  the  extremity.  Hysterical  convulsions  are  very  apt  to  be 
present  in  the  more  severe  cases.  The  menstrual  flow  is  scanty  or  normal 
in  amount  when  the  ovaries  are  cirrhotic  ;  but  with  cystic  degeneration 
the  flow  is  generally  increased,  and  hjemorrhage  may  be  the  must  promi- 
nent and  dangerous  symptom.  The  uterus  is  apt  to  be  slightly  above 
the  nonnal  size,  with  the  ovaries  in  cystic  degeneration,  and  somewhat 
smaller  when  these  organs  are  cirrhotic.  Not  infrequently  i-etroversion 
is  observed  as  a  symptom  of  cystic  ovar^y,  in  which  case  this  last-named 
organ  is  prolapsed.  The  uterus  is  commonly  free  and  movable,  unless 
ha^matocele  or  peritonitis  has  occurred.  If  cystic,  the  ovary  is  easily 
felt,  often  low  down  in  Douglas's  pouch.  If  cirrhotic,  it  is  hard  to  find. 
From  clinical  manifestations  it  appears  that  cystic  degeneration  ^is  due 
to  a  degree  of  inflammatory  action  more  severe  than  that  which  leads  to 
cirrhosis,  because  peritonitis  and  pelvic  luematocele  more  often  accom- 
pany the  formei".  Cystic  and  cirrhotic  ovaries  are  always  sensitive  to 
pressure. 

In  ovarirm  abscess  there  is  ustuvUy  a  history  of  gonorrhtpa,  puerperal 
septicaemia,  an  acute  exanthema,  or  a  severe  attack  of  metritis  or  peri- 
tonitis. When  the  abscesses  are  small,  the  symptoms  do  not  greatly 
differ  from  those  of  cystic  ovaries  ;  but  when  at  all  large,  the  patient 
has  hectic  fever  and  rigors.  The  pain  in  the  pelvis  is  constant,  but  is 
liable  to  exacerbations.  Repeated  attacks  of  pelvic  peritonitis  follow 
each  other.  When  the  ovary  is  converted  into  one  large  abscess,  and 
the  tube  is  not  affected,  dysmenorrhoja  is  not  a  constant  symptom,  and  ■ 
there  is  an  absence  of  the  nervous  phenomena  observed  in  the  other 
forms  of  ovarian  inflammation. 

The  uterus  is  usually  drawn  to  the  affected  side  as  a  result  of  the 
pelvic  peritonitis  which  usually  accompanies  these  cases.  The  lateral 
fornix  of  the  vagina  is  encroached  upon  when  the  abscess  is  large,  and 
then  fluctuation  can  be  obtained.  The  abscess,  whether  large  or  small, 
is  usually  but  part  of  the  mass  of  inflamed  tissue  which  occui^ies  the 
pelvis  on  the  affected  side.  The  ovary  is  enlarged  and  low  down.  As 
abscess  of  tlie  ovary  does  not  often  occur  alone,  and  as  the  sole  lesion 
of  the  pelvic  oj'gans  and  tissues,  the  symjitoms  which  apj)ear  are  j^artly 


LARGE  CYSTIC  TUMORS  OF  THE  OVARY.  685 

due  to  the  intercurrent  diseases— salpingitis,  h?ematocele,  peritonitis,  etc. 
When  an  ovarian  abscess  ruptures  into  the  j)eritoneal  cavity,  a  fatal 
general  j^eritonitis  is  the  result.  If  it  ojiens  into  the  vagina,  it  usually 
does  so  just  below  the  cervix  in  the  posterior  wall,  at  the  bottom  of 
Douglas's  pouch,  where  the  vaginal  wall  is  thinnest. 

Treatment. — If  the  ovarian  abscess  is  but  part  of  a  i^elvic  inflam- 
mation which  unites  together  rectum,  bladder,  uterus,  and  broad  liga- 
ment into  one  mass,  and  if  the  abscess  is  low  down,  fluctuation  being 
obtained  in  the  vaginal  roof,  it  may  be  opened  per  Tag i nam  and 
drained.  But  in  cases  of  jielvic  abscess  it  is  better  to  try  to  remove 
them  by  abdominal  section.  Exploratory  incision  has  but  little  mor- 
tality. A  certain  and  i^ositive  knowledge  of  the  condition  of  the  parts 
in  these  cases  can  be  obtained  by  abdominal  section  only,  and  by  it  only 
can  a  radical  cure  and  extirpation  of  the  abscess  be  effected.  These  are 
the  most  difficult  cases  the  surgeon  has  to  deal  with,  especially  when 
associated  with  pyo-salpinx  or  hajmatocele.  The  drainage-tube  should 
be  employed  whenever  ruptiire  of  the  abscess  occurs  in  the  efforts  at 
removal,  and  when  there  is  much  oozing  after  the  adhesions  are  In-oken 
up.  The  operation  is  similar  in  its  technique  to  that  of  removal  of  the 
tubes.  Cystic  and  cirrhotic  ovaries  are  to  be  removed  by  abdcmiinal  sec- 
tion when,  aU  conservative  measures  having  failed,  the  patient's  health 
or  reason  is  seriously  threatened.  The  objection  of  sterility  can  not  be 
maintained,  for  these  women  are  already  sterile.  The  operation  may  also 
be  performed  in  cases  of  acute  mania  and  epilepsy  which  appear  to  be 
due  to  ovarian  disease  and  which  are  incurable  by  other  means.  The 
operation  is  simple.  An  incision  large  enough  to  admit  two  fingers  is 
made  in  the  median  line.  The  lower  angle  of  this  wound  should  be 
about  two  inches  above  the  os  pubis.  Tlie  ovary  and  tube  are  freed 
from  false  attachments,  brought  toward  the  incision,  and  the  broad  liga- 
ment transfixed  close  to  the  uterus  ^vith  a  double  ligature.  The  ligatures 
are  crossed — one  is  tied  above  the  tube  close  to  the  uterus,  the  other 
below  the  ovary  ;  the  tube  and  ovary  cut  off,  and  the  ligatures  cut  short. 
The  abdominal  wound  is  closed  as  heretofore  given.  Drainage  is  rarely 
indicated. 

Large  Cystic  Tumors  of  the  Ovary  and  Broad  Ligaments. — Cystic 
tumors  of  the  ovary  are  occasionally  unilocular.  In  the  vast  majority  of 
instances  they  are  multilorular.  The  pathology  and  pathogenesis  of  these 
neoj)lasms  are  not  yet  definitely  settled,  and,  since  a  discussion  of  the  va- 
rious theories  advanced  is  scarcely  permissible  in  a  text-book,  the  student 
is  referred  to  the  various  standard  works  upon  pathology. 

The  most  common  form  of  ovarian  tumor — the  cyst-adenoma — is  al- 
ways multilocular.  The  surface  of  such  a  tumor  is  glossy,  often  silver- 
white.  The  sac  is  usually  firm,  its  contents  being  a  thick  fluid,  with  a 
grayish-brown  or  reddish  tint.  The  outline  of  the  cyst  may  be  perfectly 
symmetrical  and  roimd  ;  or  it  may  have  one  main  cyst,  and  numbers  of 
smaller  ones  springing  from  it ;  or  two  or  three  cysts  of  about  equal  size 
may  constitute  the  entire  mass.  But,  be  the  shape  what  it  may,  second- 
ary cysts  will  always  be  found  in  some  part  of  the  tumor.     At  one  or 


686  A  TEXT-BOOK   ON   SURGERY. 

more  points  the  cyst- wall  may  be  exceedingly  thin  or  softened  as  a  re- 
sult of  the  rupture  of  inter-cystic  walls,  those  of  the  secondary  cysts 
being  thinner  than  that  of  the  larger.  Softening  of  the  wall  may  also 
occur  when  the  neoplasm  is  malignant ;  or  as  a  result  of  interference 
with  its  nutrition  from  twisting  of  the  pedicle ;  or  from  suppuration 
in  the  cyst- wall.  In  exceptional  instanres  in  old  cysts  there  some- 
times exists  a  communication  between  the  cyst-cavity  and  the  bowel 
or  bladder  as  a  result  of  necrotic  changes  where  the  two  have  become 
adherent. 

In  size  cysto-adenomata  of  the  ovary  may  vary  from  a  few  inches  in 
diameter  up  to  those  of  enormous  size,  weighing  many  pounds,  and 
filling  the  entire  abdomen.  The  veins  lie  both  superficially  as  distinct 
vessels  and  dee^jly  in  the  cyst-wall  as  sinuses ;  the  arteiies  are  more 
deeply  situated  and  are  large.  This  tumor  may  be  generally  adherent 
to  the  peritonjpum  and  other  organs  with  wliicli  it  comes  in  contact,  or 
connected  at  various  points  by  isolated  bands.  In  rarer  instances  no 
adhesions  may  be  met  with.  The  pedicle  of  an  adeno-cystoma  may  be 
attached  to  both  sides  of  the  uterus,  two  distinct  tumors  having  met  and 
coalesced.  At  times  the  tumor  derives  its  nourishment  from  bands  unit- 
ing it  to  the  abdominal  parietes  or  viscera,  its  own  pedicle  having  been 
twisted  off. 

A  form  of  multilocular  cyst,  connected  with  the  ovary,  known  as 
'''RokitansJci/s  tumor,'"  has  been  observed  in  a  few  instances.  It  consists 
of  a  series  of  cysts  containing  a  clear  fluid.  The  cysts  hang  in  bunches 
and  are  connected  with  each  other  by  delicate  fibrous  bands.  The  entire 
mass  does  not  usually  reach  a  size  larger  than  the  fist. 

Dermoid  cysts  are  not  altogether  infrequent  in  the  ovary.  These  tu- 
mors have  thick  walls,  are  dark-colored,  are  filled  with  a  dark  fiuid  in 
which  are  found  particles  of  hair,  teeth,  bone,  etc.  They  may  be  mul- 
tilocular, or  they  may  contain  but  one  cyst. 

Hanging  from  the  fimbriated  extremity  of  the  Fallopian  tube,  or  just 
beneath  it,  is  also  found  a  small,  thin-walled  cyst,  with  clear  contents, 
called  by  some  the  "hydatid  of  Morgagni."  If  examined  carefully 
while  it  is  floated  in  clear  water,  it  will  be  seen  to  be  a  continuation  of 
the  horizontal  tube  of  ihe  parovarium. 

Cyst  of  the  Broad  Ligament. — There  is  also  met  with  a  cyst  of  con- 
siderable size,  with  perfectly  clear  contents  and  very  thin  walls,  which  is 
sometimes  pedunculated,  but  generally  with  a  broad  attachment  located 
either  upon  the  broad  ligament  or  the  uterus.  A  small  cyst  of  a  simi- 
lar nature  may  spring  from  the  covering  of  the  Fallopian  tube  and  be 
pedunculated,  or  arise  just  beneath  the  Fallopian  fimbrije,  and  be  either 
sessUe  or  pedunculated. 

Solid  Tumors. — Fibro-myomata  appear  as. smooth,  firm  bodies.  They 
do  not,  as  a  rule,  contract  adhesions  with  neighboring  structures. 

Sarcomata  have  about  the  same  clinical  appearance,  except  when  very 
vascular,  in  which  state  they  are  softer  and  more  elastic  than  are  fibro- 
myomata.  Carcinomata  of  the  ovary  are  very  nodular,  and  when  large 
they  may  contain  one  or  more  cavities  in  their  interiors.     Secondary 


SOLID  TUMORS.  687 

deposits  in  other  viscera  are  found  with  these  tumors.  The  symptoms 
of  all  solid  tumors  are  so  obscure  that  the  exact  character  of  any  of  these 
neoplasms  can  scarcely  be  determined,  excepting  by  microscopic  exami- 
nation. 

Symptoms. — Tumors  of  the  ovary  are  usually  first  noticed  upon  one 
side  of  the  ijelvis.  The  ordinary  cysto-adenoma  is  not  painful  until  it  is 
so  large  that  it  presses  upon  the  pelvic  and  abdominal  viscera.  If  iniiam- 
mation  supervenes  from  any  cause,  pain  is  a  prominent  symptom.  Amen- 
orrhoea  is  the  rule,  although  in  a  certain  proportion  of  cases  men- 
struation is  normal.  Menorrhagia  is  rare.  If  left  without  interference, 
pressure  upon  and  displacement  of  the  neighboring  viscera  is  the  rule, 
and,  if  peritonitis  does  not  ensue,  death  ultimately  results  from  jesthenia. 
Not  infrequently  adhesions  ai-e  formed  between  the  bladder  and  the  neo- 
plasm to  such  an  extent  that,  as  the  tumor  grows,  the  bladder  is  dragged 
upward  to  the  neighborhood  of  the  umbilicus.  In  large  tumors,  dysp- 
noea, oedema  of  the  lower  extremities,  enlargement  of  the  supei-ficial 
abdominal  veins,  and  nephritis  occur  as  a  result  of  pressure. 

Upon  examination,  it  is  usually  easy  to  detect  the  presence  of  the 
tumor.  The  uterus  lies  in  front  of  the  cyst,  or  is  displaced  laterally  if 
the  tumor  be  large  enough  to  crowd  it  out  of  its  noi-mal  position.  The 
uterus  is  not  increased  in  size,  and  is  movable  independently  of  the 
neoplasm.  The  latter  is  an  important  feature  in  differentiation,  and 
may  be  best  determined  with  the  aid  of  the  elevator  carried  into  the 
uterus.  When  the  cyst  is  large,  the  uterus  is  dragged  high  xip  and  fixed 
against  the  symphysis  pubis.  The  bladder  may  lie  over  the  front  of  the 
tumor  as  high  as  the  umbilicus.  But  when  the  tumor  is  so  large  as  to 
have  completely  risen  out  of  the  pelvis,  the  bladder  reaches,  even  when 
not  adherent  to  the  cyst,  a  point  somewhat  above  the  suprapubic  notch. 
The  enlargement  of  the  cyst  gives  to  the  abdomen  a  rotundity  not  seen 
with  distention  from  ascites  alone.  Ascites  commonly  coexists  with 
large  cysts.  If  not  large  and  non-adherent,  the  tumor  can  be  raised  out 
of  the  pelvis  without  the  uterus.  It  may  also  be  dej^ressed  in  the  pelvis. 
When  the  secondary  cysts  are  large  and  project  from  the  surface  of  the 
main  cyst,  they  may  be  quite  readily  distinguished.  If  one  hand  is 
laid  flat  upon  one  side  of  the  mass  and  the  other  side  is  given  a  sharp 
tap  with  the  fingers,  the  fluid  character  of  the  contents  of  the  neoplasm 
may  be  easily  appreciated.  When  the  walls  of  the  tumor  are  very  thick 
and  the  distention  marked,  fluctuation  may  not  be  felt. 

In  solid  ovarian  neoplasms  pain  is  apt  to  be  present  early  in  the 
history  of  the  growth,  and  the  general  health  of  the  patient  may  show 
signs  of  deterioration  before  there  is  any  marked  increase  in  the  size  of 
the  tumor.     This  is  especially  true  of  malignant  new  formations. 

Filjro-myoma  of  the  ovary  is  so  often  associated  with  similar  changes 
in  the  uterus  that  the  slight  menorrhagia  which  occasionally  accompanies 
these  cases  may  reasonably  be  ascribed  to  uterine  hyperplasia.  Upon 
abdominal  jialpation,  with  vaginal  exploration,  a  hard  and  usually  mov- 
able tumor  may  be  appreciated.  At  times  it  is  attached  to  the  surround- 
ing structures  to  such  an  extent  that  mobility  is  absent.     The  uterus  is 


688  A  TEXT-BOOK  ON  SURGERY. 

not  enlarged,  is  often  dis])lacecl  backward,  and  is  generally  freely  mova- 
ble with  small  tumors.  AV'hen  malignant,  the  tumors  are  of  rapid  growth. 
Ovarian  libr()-my<mia  grows  slowly,  gives  little  pain,  never  immediately 
infliienees  the  general  h(»alth ;  is  generally  smooth,  or  with  but  a  few 
n<xlules  ;  not  very  sensitive,  and  is  usually  freely  movable  indei)endently 
of  the  uterus.  Dermoid  tumors  may  appear  clinically  as  cystic  or  solid, 
according  as  their  fluid  or  sdlid  contents  predominate.  Adenocystoraata 
and  dermoid  cysts  are  occasionally  met  with  in  young  children. 


Laparotomy  fou  tiik  Removal  of  Tumors  of  the  Ovaky  and 

Fallopian  Tube. 

The  removal  of  a  tumor  of  the  ovary,  broad  ligament,  or  Fallopian 
tube,  cystic  or  solid,  is  performed  as  follows  : 

Preparation  of  the  Patient. — For  several  days  before  the  operation, 
the  patient  should  be  put  on  a  fluid  diet,  and  have  a  movement  of  the 
bowels  every  day  for  at  least  a  week  before  the  operation.  For  twelve 
hours  before  taking  ether,  the  stomach  should  be  kept  perfectly  free 
from  any  solid  food  or  milk.  About  two  ounces  of  whisky  in  an  equal 
quantity  of  water  should  be  taken  a  half-hour  before  the  anaesthesia  is 
commenced.  All  the  details  of  the  antiseptic  method  heretofore  given 
should  be  carefully  carried  out.  In  hospital  practice,  and  in  the  dusty 
season  of  the  year,  the  carbolic-acid  spray  should  be  kept,  going  in 
the  operating-room  for  a  half-hour  prior  to  the  entrance  of  the  patient. 
The  pubes  and  abdominal  wall  through  which  the  incision  is  to  be  made 
should  be  shaved  and  disinfected,  and  the  bladder  emptied  before  the 
inhalation  is  begun,  unless  the  nervous  condition  of  the  patient  renders 
it  advisable  to  postpone  this  part  of  the  j^rei^aration  for  the  operation 
until  she  is  unconscious.  The  legs,  arras,  and  chest  should  be  carefully 
wrapped  in  warm  flannels  or  blankets.  The  patient  should  rest  ujion 
the  back,  with  the  legs  fully  extended,  or,  as  many  operators  prefer,  with 
the  sacrum  resting  near  the  end  of  the  table,  and  the  feet  in  a  chair, 
with  the  thighs  abducted  and  held  by  an  assistant  seated,  between  the 
feet,  in  the  chair.  The  incision  should  be  in  the  median  line,  about 
three  inches  in  length,  and  should  commence  about  five  inches  above 
the  OS  piibis.  The  recti  muscles  should  be  separated  and  all  bleeding 
arrested  by  catgut  ligatures  before  the  peritonaeum  is  opened.  When 
the  parietal  layer  of  the  peritonseum  is  reached,  catch  a  small  point  of 
this  membrane  with  a  tenaculum  or  forceps,  grasp  this  point  between 
the  thumb  and  finger,  to  make  sure  that  no  omentum  or  intestine  is 
picked  up,  and  make  a  small  incision  with  the  scissors.  Through  this 
opening  introduce  the  broad-grooved  director,  and  further  divide  the 
peritonaeum.  Two  fingers  should  now  be  carried  into  the  abdomen,  and  a 
careful  exploration  made.  A  blunt,  round  instrument  (a  No.  20  United 
States  urethral  sound  will  suffice)  carried  in  and  swept  over  the  tumor 
will  demonstrate  the  presence  of  any  adhesions  between  it  and  the  ante- 
rior wall  of  the  abdomen.     If  the  tumor  is  free,  drag  it  up  to  the  incis- 


LAPAROTOMY  FOR  THE   REMOVAL   OF   TUMORS. 


689 


iio.  066.  — Showing  the 
manner  in  whioh  the  two 
threads  of  a  double  liga- 
ture should  he  crossed 
in  the  center  of  the  ped- 
icle. 


ion ;  and,  if  it  is  cystic,  hold  it  so  that  witli  the  aid  of  sponges  placed 
around  the  margins  of  the  incision  none  of  the  fluid  can  escape  into  the 
peritoneal  cavity.  Introduce  the  large  trocar  and  evacuate  the  fluid 
contents.  As  the  sac  is  being  emptied,  drag  it  farther  out  of  the  incis- 
ion, and,  when  all  the  fluid  escapes,  free  the  tumor  of  all  adhesions  to 
the  intestines  or  other  structures.  All  large  adhesions  may  be  tied  with 
the  double  catgut  ligature,  and  cut  between,  while  small  adhesions,  or 
those  so  situated  that  the  ligature  is  impossible,  should  be  torn  throiigh. 
Great  care  is  required  in  separating  the  sac  from  the  wall  of  the  intes- 
tine. As  soon  as  the  pedicle  is  freed,  the  sac  should  be  grasped  with  a 
long- jawed  pedicle  forceps  (Spencer  Wells's  sac-forceps)  and  cut  away. 
The  pedicle  .should  be  transfixed  near  its  middle  with  an  aneurism-needle 
armed  with  a  large  double  silk  ligature  and  the  two  threads  drawn 
through.  In  tying  the  threads  on  either  side  of  the 
pedicle  cross  them,  as  shown  in  Fig.  666,  and  tie 
firmly.  If  the  pedicle  does  not  bleed,  the  ligatures 
should  be  cut  short.  The  ovary  of  the  opx^osite  side 
should  be  examined.  The  cavity  of  the  peritoneeum 
should  be  carefully  washed  out  with  Thiersch's  solu- 
tion, with  the  aid  of  sponges  on  holders,  and  the 
wound  closed  as  directed  in  laparotomy  for  intestinal  obstruction.     If  a 

solid  tumor  is  encountei'ed,  and  when  a  cystic 
tumor  has  such  thickened  walls  that  it  can 
not  be  readily  brought  out  at  the  wound,  the 
incision  may  be  enlarged.  It  is,  however, 
advisable  to  keeja  the  abdominal  wound  as 
small  as  possible  when  the  small  size  of  the 
opening  does  not  interfere  with  the  safe 
manipulation  within  the  abdomen.  Derm- 
oid cysts  are  usually  so  solid  that  they  are 
removed  without  an  efl'ort  at  tap^iing. 

A  cyst  of  the  broad  .ligament,  in  which 
there  is  no  pedicle,  requires  to  be  stripped 
out  of  the  capsule,  the  capsule  stitched  to 
the  margins  of  the  abdominal  incision,  the 
cyst-wall  beyond  the  line  of  sutures  cut 
away,  and  a  drainage-tube  inserted. 

The  tube  of  Dr.  H.  Marion-Sims  is  a  most 
satisfactory  ajiparatus  for  draining  the  pel- 
vis after  laparotomy  for  any  jiui-pose  for 
which  after-drainage  is  indicated  (Fig.  667). 
"It  consists  of  a  large  and  a  small  tube 
made  of  hard  rubber.  The  smaller  tube  is 
inside  of  the  larger  one,  running  along  the 
posterior  wall  and  terminating  about  an  eighth  of  an  inch  from  the  bot- 
tom. The  large  tube  is  perforated  on  the  sides  and  curved  at  the  top, 
so  that,  when  in  the  abdominal  wound,  the  top  of  the  tube  jirojects 
nearly  over  the  symphysis  pubis.     To  this  a  rubber  tube,  of  sufiicient 

44 


Fio.  667.— Dr.  H.  Marion- Siius'a 
drainage-tube. 


690  A  TEXT-BOOK   ON   SURGERY. 

length  to  carry  the  fluid  used  in  washing  out  tlie  abdomen  into  a 
convenient  vessel,  is  attached.  The  injection-fluid  is  forced  in  by  a 
Davidson's  syringe,  the  tube  of  whicli  is  slipped  over  the  end  of  the 
small  pipe  B  ;  or  a  fountain  irrigator  may  be  preferred.  As  the  wound 
fills,  the  fluid  escapes  tlirougli  the  larger  tul)e,  and  the  irrigation  should 
be  continued  until  the  water  comes  out  clear.  By  the  siplion  action  of 
this  apparatus  the  discharge  from  the  greater  tube  will  be  continued 
after  the  injection  is  stopped.  Just  as  the  stream  Is  about  to  stop,  the 
tubes  should  be  closed,  and  in  this  way  the  entrance  of  aii'  is  prevented. 
The  lower  end,  C,  of  this  tube  should  be  placed  in  the  most  dexjendent 
portion  of  the  cavity,  usually  in  Douglas's  cul-de-sac." 


CHAPTER   XX. 


DEFORMITIES. 


DEFORMITIES   OF  THE   SPINAL    COLUMN. 


Ant  noticeable  deviation  from  the  normal  curvatures  of  the  vertebral 
column  constitutes  a  deformity.  They  are  congenital  and  acquired,  tem- 
porary ox  permanent.  They  are  divisible  into  two  great  classes,  namely, 
those  due  to  lesions  of  the  column  (bones  or  cartilages),  and  those  due 
to  lesions  of  the  soft  tissues  (muscles  and  ligaments).  To  the  former 
belong  dislocations,  fractures,  destructive  ostitis,  and  spina  bifida  ;  to  the 
latter,  muscular  torticollis,  lateral  or  rotary -lateral  curvatui'e  (scoliosis), 
stoop-shoulder  {cyphosis),  curvature  from  pleuritic  adhesions,  collapse 
of  the  lung,  contractions  of  cicatrices  following  burns,  scalds,  phleg- 
mon, etc. 

Lateral  and  Rotary-lateral  Curvature. — Simple  lateral  curvature  of 
the  spine — that  is,  a  bowing  to  one  side  without  rotation  of  the  vertebrse — 
is  extremely  rare.  It  may  occur  in  any  portion  of  the  column  to  a  slight 
extent,  although  rotation  is  very  apt  to  take  place  with  the  curvature. 
It  is  more  often  observed  in  the  cervical  region  than  elsewhere,  and  is 
known  as  torticollis,  or  '"  wry-necTc.'''' 

The  causes  of  wry-neck  are — 1,  loss  of  parallelism,  or  balance  of 
power  between  opposing  muscles,    and    2, 
cicatricial  contractions. 

Muscfular  torticollis  is  by  far  the  most 
frequent  form,  and,  in  common  with  all  de- 
formities resulting  from  lesions  of  the  mus- 
cles, the  right  side  is  usually  affected.  The 
right  sterno-mastoideus  muscle  is  the  prin- 
cipal seat  of  tonic  spasm,  causing  this  or- 
gan to  stand  out  in  relief  ;  the  right  ear  is 
drawn  down  toward  the  clavicle  of  that  side, 
while  the  chin  points  well  to  the  left  (Fig. 
668).  The  trapezius  not  unfrequently  is  con- 
tracted with  the  mastoid  muscle.  The  sple- 
nius,  scaleni,  platysma  myoides,  or  levator- 
anguli  scapuljB,  are  less  frequently  involved. 
Loss  of  equilibrium  between  the  muscles  of 

the  two  sides  occurs  chietly  in  chlorotic  patients  in  \Ahich  the  normal 
muscular  tone  is  greatly  diminished,  rendering  the  organs  of  the  left  (or 


Fia.  668. — Muscular  torticollis. 
(After  Sayre.) 


692 


A  TEXT-BOOK   ON  SURGERY. 


non-preferred)  side  nnable  to  resist  the  more  developed  muscles  of  the 
right  half  of  the  body.  In  other  cases  the  lesion  may  be  situated  in  the 
central  nervous  ganglia,  or  in  tin-  trark  of  the  nerve. 

luilanimation  of  the  muscular  substance  (myositis),  or  of  the  tendons 
or  sheaths  of  the  muscles,  is  an  occasional  cause  of  wry-neck.  Any  in- 
Hammatory  process  may  lead  to  shortening  of  the  musch's,  and  to  con- 
tractions in  the  fascia  and  connective  tissues  of  the  neck.  Muscular 
torticollis  is  met  with  most  frequently  in  the  young,  may  exist  at  birth, 
is  seen  in  females  oftener  than  in  males,  and  in  this  class  of  cases  is  apt 
to  occur  about  the  age  of  ])ul)erty.  In  some  instances,  in  addition  to 
the  tonic  spasm  of  the  muscles  involved,  a  clonic  or  irregular  convulsive 
movement  occurs. 

Diagnosis. — The  recognition  of  torticollis  is  usually  free  from  diffi- 
(ailty.  The  elimination  of  caries,  dislocation,  fracture,  and  wry-neck 
caused  by  cicatricial  contractions,  is  determined  from  the  history  of  the 
case  and  by  inspection  and  manipulation. 

When  one  sterno-mastoid  muscle  is  contracted,  the  chin  is  pointed  to 
the  opposite  side,  and  the  occiput  made  to  approximate  the  clavicle  of 
the  side  corresponding  to  the  contracted  muscle.  The  splenius  capitis 
draws  the  mastoid  process  downward  and  l)ackward  toward  the  spine  of 
the  seventh  cervical  vertebra. 

The  prognosis  in  muscular  torticollis  is  iisually  favorable — less  so  in 

clonic  than  in  tonic  muscular  spasm.  In 
wry-neck  due  to  contractions  of  the  fas- 
ci;c,  tendons,  etc.,  the  deformity  is  with 
difficulty  relieved. 

Treatment. — Chlorosis,  or  any  dys- 
crasia,  should  be  treated  by  tonics  and 
internal  medication,  by  propei-ly  select- 
ed diet  and  out-of-door  life.  The  devel- 
opment of  the  muscles  of  tlie  left  (or 
weaker)  side  is  essential.  Kneading, 
massage,  and  electricity  will  be  found 
useful  adjuvants.  Mechanical  api)liances 
should  be  used  in  overcoming  tlie  con- 
tractions in  the  oifending  muscles.  Arti- 
licial  muscles,  composed  of  elastic  bands 
or  rubber  tubing,  more  nearlj^  fulfill  the 
indications.  The  origin  and  insertion 
should  correspond  to  that  of  the  normal 
muscle.  A  thoracic  belt  or  jacket  of 
plaster  of  Paris,  le^ither,  or  silicate  of 
soda,  properly  adjusted,  will  serve  for 
the  points  of  fixation  of  the  lower  end 
of  the  elastic  material.  The  upper  in- 
sertion near  the  occiput  is  best  secured 
by  a  stall  carried  around  the  head  above  the  ears  and  across  the  fore- 
head.    In  order  to  prevent  it  from  slipping,  the  portion  which  rests 


Fio.  669. — Eeynders's  app.ir.nt»s  for  the  cor- 
rection" of  musculiir  torticollis. 


MUSCULAR  TORTICOLLIS.  693 

upon  the  skin  of  the  forehead  should  be  made  of  strong  adhesive  plas- 
ter (as  advised  by  Prof.  Sayre).  The  tension  on  the  rubber  muscle  may 
be  increased  from  day  to  day,  if  necessary.  If  this  method  does  not 
succeed,  the  apparatus  of  Reynders  &  Co.  (Fig.  669)  should  be  tiied. 
The  mechanism  is  well  shown  in  the  accompanying  cut,  the  correction 
of  the  deformity  being  effected  by  means  of  a  series  of  joints  situated 
at  the  back  of  the  neck,  which  are  worked  by  a  key,  and  can  be  fixed  at 
any  angle  of  flexion  and  rotation. 

The  operative  j^rocedures  include  stretching  or  division  of  the  muscle 
or  muscles  affected,  tenotomy,  neurectomy,  division  of  the  fascia,  and 
the  free  dissection  of  cicatricial  tissue.  Of  these  operations,  tenotomy 
of  the  sterno-mastoideus  is  most  frequently  demanded.  A  puncture  is 
made  a  little  to  the  outer  side  of  the  clavicular  tendon  of  this  muscle, 
and  a  long,  probe-pointed  tenotome  slid  flatwise  (the  cutting-edge  down- 
ward) upon  the  outer  anterior  surface  of  the  clavicle.  As  soon  as  the 
point  of  the  instrument  has  passed  between  the  clavicular  and  sternal 
origins,  the  edge  is  turned  outward,  making  the  muscle  tense,  and  the 
tendon  is  divided  subcutaneously.  The  sternal  origin  is  divided  by  an 
additional  puncture.  After  tenotomy  the  prothetic  apparatus  should  be 
employed  until  recovery  is  complete.  In  dividing  the  body  of  this  mus- 
cle, or  the  trapezius,  splenius,  or  levator-anguli  scapulae,  the  open  method 
should  be  followed. 

Violent  and  sudden  stretching  of  the  muscles,  with  or  without  anaes- 
thesia, is  not  advisable.  Exsection  of  that  portion  of  the  spinal  acces- 
sory nerve  which  is  supplied  to  the  sterno-mastoid  and  trapezius  mus- 
cles is  occasionally  performed  in  order  to  paralyze  the  permanently  con- 
tracted muscles.  It  is  preferable  to  a  simple  division  or  to  stretching 
of  the  nerve,  for  the  reason  that  a  divided  nerve  may  reunite,  and,  after 
stretching,  the  function  of  the  nerve  is  only  temporarily  impaired. 

In  order  to  expose  this  nerve,  make  an  incision  about  four  inches  in 
length,  following  the  posterior  border  of  the  sterno-mastoideus  muscle, 
and  commencing  on  a  level  with  a  point  half-way  between  the  lobule  of 
the  ear  and  the  angle  of  the  Jaw.  The  fibers  of  the  muscle  should  be 
sought,  and,  recognizing  these,  the  posterior  edge  is  exposed.  By  keep- 
ing the  wound  dry,  and  working  close  to  the  under  surface  of  the 
muscle,  the  vessels  will  be  avoided  and  the  nerve  will  be  seen  running 
obliquely  downward  and  outwai'd,  and  passing  into  the  muscle.  One 
or  two  supeiiicial  nerves  are  sometimes  seen  radiating  from  the  cer- 
vical plexus.  From  one  half  to  one  inch  of  the  nerve  should  be  ex- 
cised. After  this  operation,  mechanical  treatment  should  be  instituted 
for  a  short  time. 

In  torticollis  due  to  cicatrices,  simple  division  of  the  contracting  tis- 
sue affords  only  temporary  benefit.  The  only  legitimate  method  is  to 
dissect  out  the  offending  tissue,  slide  sound  skin  over  the  wound  thus 
made,  and  use  mechanical  treatment  until  the  deformity  is  overcome. 

Deformities  due  to  dislocations  and  fractures  of  the  cervical  verte- 
brae have  been  considered,  and  those  resulting  from  caries  of  this  portion 
of  the  spine  will  be  given  hereafter. 


694 


A  TEXT-BOOK   ON   SURGERY. 


Lateral  and  Rotary -lateral  Currature  of  the,  Dorso-lumhar  Spine. — 
Simple  lateral  curvature  of  the  dorso-lumhar  spine  is  exceedingly  rare. 
It  is  complicated  in  almost  all  cases  by  rotation  of  the  vertebrae  upon 
each  other,  and  in  deformity  here  from  muscular  causes,  the  rotation 
precedes  the  lateral  curvature. 

Lateral  curvature  is  usually  caused  by  an  inequality  in  the  length  of 
the  lower  extremities.  Fig.  671  was  taken  from  a  boy  in  whom  the  right 
extremity  was  one  and  a  half  inch  shorter  than  the  left.  With  both 
soles  on  the  same  plane,  marked  lateral  curvature  (convexity  to  the  right) 
was  observed.  By  placing  the  foot  of  the  short  side  upon  a  book  f)f  the 
required  thickness,  the  deformity  disappeared  (Pig.  672l. 


Fio.  670. — Lateral  curvature  after  recov- 
ery from  lumbo-sacrul  .spoudylilis. 


Fio.  671. 


Fig.  672. 


Inequality  in  the  length  of  the  lower  extremities  is  not  uncommon, 
even  in  individuals  who  have  not  suffered  from  injury  or  disease.  A  dif- 
ference of  as  much  as  one  inch  has  been  noted,  while  from  one  half  to 
one  fourth  inch  is  quite  common. 

Cicatricial  contractions  on  one  side  of  the  chest  or  abdomen,  as  after 
extensive  bums  or  in  chronic  pleuritic  adhesions  with  collapse  of  the 
lung,  also  produce  this  deformity.  The  treatment  will  be  considered 
with  that  of  rotary-lateral  curvature. 

Rotary-lateral  Curvature. — Rotation  of  the  bodies  of  the  vertebrse 
upon  each  other,  and  upon  the  sacrum  and  subsequent  or  simultaneous 
lateral  curvature,  is  one  of  the  most  difficult  deformities  to  correct.  The 
chief  cause  is  loss  of  the  normal  equilibrium  of  the  muscles  of  the  two 
sides  of  the  trunk.     The  tendency  to  deformity  is  increased  by  the  habit 


ROTARY-LATERAL   CURVATURE. 


695 


of  sitting  sidewise  at  the  table  or   desk,  vnth   one  shoulder  drooping 
while  the  other  is  elevated.     A  large  majority  of  those  affected  are  chlo- 
rotic  girls,  l^etween  thirteen  and  eighteen  years  of  age.     This  deformity 
is  occasionally  met  with  in  porters  or  laborers 
who  habitually  caiTy  heavy  weights  upon  one 
shoulder.     The  rotation  most  frequently  com- 
mences in  the  lumbar  region.     The  spines  twist 
to  the  right,  while  the  anterior  aspect  of  the 
bodies  of  the  vertebrae  are  made  to  look  toward 
the  left.     The  convexity  of  the  curve  is  to  the 
left,  the  right  shoulder  is  prominent,  the  apex 
tilted  outward,  the  angles  of  the  ribs  on  this 
side  project  abnormally,  and  there  is  a  folding 
in  or  wrinkling  of  the  skin  between  the  iliac 
crest  and  the  thorax  (Fig.  673). 

The  chief  agent  in  this  distortion  is  believed 
to  be  the  latissimus-dorsi  muscle.  Acting  upon 
the  tips  of  the  long  spines  of  the  lumbar  verte- 
brae from  its  insertion  in  the  humerus  (and  indi- 
rectly through  the  pectoralis  major,  from  the 
clavicle  and  sternum),  the  spines  are  twisted  to 
the  right,  causing  the  rotation  of  the  bodies  to 
the  left ;  the  shoulder-blade  is  tilted  outward, 
and  the  ribs  are  bent  under  the  contraction  of 
this  long  and  comparatively  powerful  muscle. 

In  some  instances  the  abdominal  muscles  take 
part  in  the  unilateral  contraction,  whOe  in  oth- 
ers the  deformity  commences  with  the  rotation  of  the  dorsal  vertebra^  by 
the  action  of  the  serratus-magnus  and  rhomboidei  muscles.     No  matter 
where  the  primary  curve  takes  place,  a  second  or  compensatory  curve 
follows  in  all  chronic  cases. 

The  diar/nosis  of  rotary-lateral  curvature  will  depend  upon  the  promi- 
nence of  the  shoulder-blade,  bulging  of  the  ribs,  and  the  approximation 
of  the  crest  of  the  ilium  and  thorax  of  the  right  (or  affected)  side.  Ca- 
ries of  the  spine  may  be  eliminated  by  the  absence  of  abnormal  tempera- 
ture, freedom  from  pain  when  direct  pressure  is  made  from  the  head 
along  the  vertebral  column,  and  absence  of  symptoms  of  compression  of 
the  cord  or  nerves  in  the  intervertebral  notches.  Psoas  abscess  is  pres- 
ent in  a  certain  proportion  of  cases  of  ostitis  of  the  vertebrae. 

In  simple  lateral  curvature  the  ribs  are  not  projected,  as  when  rota- 
tion occurs,  nor  is  the  tip  of  the  shoulder-blade  so  prominent. 

The  prognosis  varies  with  the  character  of  the  lesion.  In  recent 
lateral  curvature,  due  to  inequality  of  length  in  the  extremities,  it  is 
favorable.  In  rotary-lateral  curvature,  within  the  first  few  months  of 
the  lesion,  a  cure  may  be  effected.  In  old  cases,  while  the  deformity 
may  be  aiTested,  it  is  difficult  and  often  irapossilile  to  restore  the  nor- 
mal contour  of  the  spine  and  ribs. 

Treatment. — When  the  lesion  is  due  to  loss  of  equilibrium  in  tlie 


Fig.  673. — Rotaiy-lateral  curra- 
ture  in  a  girl  fifteen  yeara 
of  age. 


696 


A  TEXT-BOOK   OX   SURGERY. 


Fia.  G74.— Piitient  lying  in  a  position  to  overcome  contraetion  of  the 
muscles  of  tlie  Ujl  side  of  the  abdomen  and  thorax.  (After 
Keeves.) 


muscles  of  the  two  sides,  especial  attention  should  be  directed  to  the 
development  of  the  organs  of  the  weaker  side,  and  at  times  it  is  neces- 
sary to  impair  the  nutrition  of  the  muscles  of  the  sti'oii^er  half  of  the 

trunk.  When  tlie  de- 
formity is  on  the  right 
side,  the  muscles  of  the 
left  arm  and  side  should 
be  exercised  by  the  use 
of  the  dumb-bells,  elas- 
tic strap,  swing,  or  hori- 
zontal bar.  It  is  often 
advisable  to  place  the 
right  arm  and  hand  in 
a  sling,  to  prevent  the 
further  development  of 
these  muscles.  Mass- 
age or  kneading,  con- 
hned  to  the  left  half  of 
the  body,  and  the  gal- 
vanic current  to  the  same  region  two  or  three  times  a  week  will  be  advis- 
able. Tonics,  judicious  feeding,  and  out-of-door  life  are  essential  feat- 
ures of  treatment.  The  patient  should  be  directed  to  sit  squarely  upon 
the  buttocks,  and  not 
to  droop  or  loll  to  one 
side.  In  reclining,  the 
body  should  be  j^laced 
in  such  a  position  that 
the  offending  muscles 
are  put  upon  the  stretch 
(Fig.  674).  The  de- 
formity is  temporarily 
overcome  by  the  em- 
ployment of  Wolff's 
cradle  (Fig.  675).  The 
belt  passes  over  the 
projecting  ribs  and 
shoidder  -  blade,     thus 

bringing  the  weight  of  the  trunk  upon  these  parts,  while  gravity  aids  in 
overcoming  the  curvature  in  the  lumbar  region. 

In  a  certain  proportion  of  cases,  mechanical  support  of  the  thorax  is- 
indicated,  especially  in  those  cases  where  from  muscular  weakness  it  is 
almost  impossible  to  hold  the  sjiine  erect.  For  this  purpose  the  plaster- 
of-Paris  jacket  or  the  perforated  corset  may  be  used.  The  latter  (Figs. 
676,  677)  I  have  found  very  satisfactory.  'It  is  to  be  commended,  for  the 
reason  that  it  can  be  readily  removed  at  night,  and  is  more  cleanly  than 
a  permanent  plaster  jacket.  When  the  gypsum  is  applied  it  should  be 
split  down  the  front,  taken  off  and  fixed  for  lacing  so  that  it  may  be 
removed  when  necessary. 


Fig.  675. — Wolff's  suspensorv  cradle.  Patient  in  position  when  the 
contraction  is  on  the  ritrlit  side  (with  the  right  shoulder-blade 
and  ribs  projecting.     (After  Eeeves. j 


ROTARY-LATERAL   CURVATURE. 


697 


This  perforated  corset  is  made  as  follows :  A  plaster-of- Paris  jacket 
is  applied  as  hereafter  directed,  and  as  soon  as  this  hardens  (in  from  ten 
to  thirty  minutes)  it  is  si:)lit  down  the  median  line  in  front,  removed 
from  the  body,  and  the  cut  edges  placed  and  held  in  ajjposition  by  a 
bandage  carried  around  and  over  the  entire  jacket.  This  shell  is  to  be 
used  as  a  mold  in  which  a  cast  of  the  deformed  thorax  is  to  be  nuide. 
It  is  thoroughly  greased  on  its  inner  surface,  placed  upon  the  floor,  and 
filled  with  stiff  plaster-mortar.  When  this  hardens,  the  shell  is  removed, 
leaving  an  exact  cast  of  the  tho- 
rax, upon  which  the  corset  is  to 
be  built. 

The  materials  needed  are  white 
glue,  ordinary  muslin  rollers,  flat 


Fig.  616. — Corset  made  after  Vance's  method. 


Fig.  C77.— The  same,  applied. 


spring  steel  about  one  eighth  of  an  inch  wide  and  very  thin,  and  one 
yard  of  Canton  flannel.  Place  the  flannel  with  the  soft  plush  next 
to  the  plaster,  and  stitch  this  tightly  to  the  model,  so  that  it  is  not 
wrinkled.  It  should  be  sewed  only  along  the  middle  line  in  front.  The 
glue  should  now  be  dissolved  in  warm  water.  Strips  of  bandage  about 
two  feet  long  and  two  inches  in  width  are  dipped  in  the  glue  and  laid 
on  the  flannel  which  is  around  the  model.  As  soon  as  a  single  thick- 
ness has  been  applied,  strips  of  the  steel  wire,  cut  not  quite  as  long 
!s  the  corset,  are  placed  one  inch  apart  over  its  entire  surface,  and 
hekl  in  place  by  a  string  wotind  around  as  they  are  laid  on.  A  long, 
dry  roller  is  next  carried  around  the  model  from  above  downwaid, 
and  drawn  so  tight  that  the  steel  springs  are  made  to  conform  exactly 
to  the  surface  of  the  conset.  I'pcm  this  two  additional  layers  of  the 
short  strips  of  roller  dipped  in  glue  are  laid.  The  corset  sliould  be  left 
for  several  hours  in  the  hot  sun,  or  by  a  fire,  until  it  is  thoroughly 
dried.  It  is  then  split  down  the  front,  removed,  and  the  edges  bound 
with  chamois-skin.     Hooks  for  lacing  should  be  fastened  along  the  edges 


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A  TEXT-BOOK  ON  SURGERY. 


in  front.  Perforations  may  be  made  between  the  springs  with  a  wad- 
ding-punch. This  apparatus,  when  properly  made,  fits  accurately  about 
the  body  in  the  most  favorable  ])()si(i(iii  for  tlie  correction  of  the  defonn- 
ity.  It  can  be  removed  at  night  upon  retiring  and  for  bathing,  changes 
of  clothing,  massage,  and  electricity.  It  is  lighter  and  cleaner  than  the 
plastP7--of-Paris  jacket.  When  the  necessary  materials  can  not  be  had, 
the  j)laster  jacket  should  be  employed. 

Operative  interference  in  muscular  scoliosis  is  rarely  called  for.  In 
extreme  cases,  when  the  latissimus  dorsi  of  one  side  is  greatly  shortened 
and  increased  in  development,  correction  of  the  curvature  may  be  expe- 
dited by  the  subcutaneous  division  of  this  muscle. 

When  lateral  or  rotary -lateral  curvature  of  the  spine  results  from  in- 
equality in  the  length  of  the  lower  extremities,  the  first  indication  in 
treatment  is  to  elevate  the  shoe  of  the  short  side,  and  thus  bring  the 
plane  of  the  iliac  crests  at  a  right  angle  to  the  axis  of  the  vertebral 
column.  IE  the  deformity  is  not  entirely  corrected  by  this  plan,  the 
measures  just  detailed  should  be  also  employed. 

When  the  deformity  is  caused  by  suijerficial  cicatricial  contractions, 
their  division  is  essential.  In  pleuritic  adhesions,  with  collapse  of  the 
lung,  the  treatment  given  for  rotary-lateral  curvature  due  to  muscular 
asymmetry  should  be  adopted. 

Anterior  and  Posterior  Currature  of  the  F!pine. — Anterior  curvature, 
or  "stoop-shoulder,"  usually  occurs  in  the  dorso-cervical  regions;  occa- 
sionally the  entire  column  is  involved.  It  may  be  caused  by — 1,  partial 
or  complete  paralysis  of  the  erector  muscles  of  the  back  ;  2,  tonic  spasm 
of  the  abdominal  muscles  ;  8,  from  inadvertence,  as  in  the  habit  of  allow- 
ing the  shoulders  to  droop  forward,  with  or  without  the  carrying  of  bur- 
dens ;  4,  cicatricial  contractions  in  the  anterior  thoracic  and  abdominal 
regions ;  5,  heredity. 

Complete  paralysis  of  the  muscles  of  the  back  is  exceedingly  rare. 
Unilateral  i)aresis  is  not  altogether  uncommon.  The  most  frequent 
condition  is  one  of  general  impairment  of  muscular  tone,  the  head  and 

upjjer  spine  gravitating  forward 
as  the  muscles  yield,  until  the 
posterior  ligaments  are  elongated 
and  the  anterior  margins  of  the 
intervertebral  disks  narrowed  by 
compression.  The  habit  of  car- 
rying a  heavy  burden  upon  one 
shoulder  is  more  likely  to  in- 
duce rotary-lateral  curvature  than 
ci/pJiosis.  The  indications  are  to 
correct  the  deformity  by  the  use 
of  braces,  and  to  increase  the  tone 
of  the  muscles  the  nutrition  of  which  is  impaired. 

To  meet  the  former,  in  mild  cases  a  double  elastic  brace,  such  as  is 
shown  in  Fig.  678,  will  be  sufficient.  Massage,  electricity,  tonics,  and 
out-of  door  life  are  also  essential  features  of  treatment. 


Fig.  678. — Nyrop's  spring-brace.     (After  Reeves.) 


SPONDYLITIS.  699 

Posterior  curvature  of  the  spine,  lordosis  or  "sway-back,"  is  far  less 
frequent  than  the  condition  just  described.  It  occurs  almost  always  in 
the  lumbar  resrion.  In  the  later  montlis  of  pregnancy  it  is  a  common 
condition,  and  is  met  with  in  individuals  with  unusual  development  of 
the  stomach  and  abdominal  viscera,  or  in  cases  of  chronic  abdominal 
tumor  (fibroid,  etc.). 

Spondylitis. — Destructive  ostitis  of  the  vertebrge,  commonly  known 
as  Pott's  disease,  occurs  usually  between  the  third  and  fifteenth  year  of 
life.  In  exceptional  instances  it  is  observed  prior  to  three  years  of  age, 
wliile  not  more  than  one  fifth  of  all  cases  occur  after  the  fifteenth  year. 
It  is  therefore  eminently  a  disease  of  the  growing  jjeriod,  when  rapid 
nutritive  changes  ai-e  taking  place  in  the  bones. 

While  no  i>ortion  of  the  spine  is  exempt,  the  disease  is  much  more 
frequent  in  the  dorsal  vertebrge,  which  are  involved  in  about  two  thirds 
of  all  cases.  The  lumbar  and  cervical  portions  of  the  column  are  about 
equally  liable  to  destructive  ostitis.  Occipito-cervical  disease  is  rare. 
Ostitis  in  the  lower  cervical  region  is  apt  to  involve  the  upper  dorsal  by 
extension,  and  the  same  is  true  of  ostitis  of  the  lower  dorsal  in  their 
relation  to  the  lumbar  vertebra;.  Lumbo-sacral  disease  is  not  altogether 
uncommon.  Destructive  ostitis  of  the  spine  is  divided  into  occrpito- 
cervical,  cervical,  cervico-dorsal,  dorsal,  dorso-lumbar,  lumbar,  and 
lumbo-sacral,  according  to  the  recognized  location  of  the  disease. 

Causes — Predisposing  and  Exciting. — Any  disturbance  of  the  nor- 
mal process  of  nutrition  in  the  tissues  in  general — as  in  the  syi:)hilitic, 
tubercular,  goiity,  or  rheumatic  dyscrasia — or  the  impairment  of  vitality 
resulting  from  any  acute  disease,  predisposes  to  inflammatory  changes  in 
the  bones,  and  especially  in  the  cancellous  tissue  of  the  vertebra?.* 
These  bones,  together  with  the  sternum  and  ribs,  are  the  last  to  take  on 
the  changes  which  occur  in  the  adult  bones — the  bones  of  comi:)leted 
gTowth  and  full  development.  In  the  pathology  of  ostitis  it  has  been 
Ijointed  out  that  the  medulla  of  these  bones  remains  in  its  red  or  embry- 
onic condition  long  after  that  in  the  other  bones  has  undergone  the  adult 
change,  and  that,  consequently,  they  are  for  a  prolonged  period  liable 
to  accidents  consequent  upon  rapid  nutritive  changes,  and  especially  to 
capillary  rupture  and  extravasation,  f  How  much  more  liable  to  acci- 
dent and  disastrous  inflammation  are  these  structures  Avhen  they  are 
weakened  in  the  general  impairment  of  nutrition?  The  chief  exciting 
cause  is  violence,  either  directly  or  indirectly  applied.  A  fall  upon  the 
feet,  buttocks,  or  hands,  or  violent  flexion  or  extension  of  the  vertebral 
column,  a  blow  upon  the  sternum  or  ribs,  or  a  penetrating  wound,  may 
each  lead  to  destructive  ostitis.  Carcinoma,  sarcoma,  and  aneurism  may 
also  cause  destruction  of  one  or  more  vertebrae.     It  is  believed  that  as 

*  "  Les  tubercLilcs  dcs  os  s'sobservent  haliituollement  dans  les  tissii  spongionx  iles  os  longs  et 
dans  les  os  courts,  mais  leur  si6ge  de  prfidileetion  est  le  corps  des  vert6bres,  lo  sternum  ot  les 

C6te8." — CORNIL  ET  Ranvier. 

t  "Les  OS  des  jeunes  sujets  et  coux  qui  chez  I'adulte  contionnent  encore  la  moelle  foetale 
comme  le  storniim  et  les  corjis  vertebraux  sont  partieuli^rement  expos6  aus  troubles  patho- 
logiques  nutritifs  ou  fonnateurs."' — Cohsil  et  Kanvieb. 


700 


A  TEXT-BOOK   ON   SURGERY. 


between  the  predisposing  and  exciting  causes  of  Potfs  disease,  the  for- 
mer deserve  by  far  the  greater  consideration. 

Clinically,  destructive  ostitis  is  met  with  in  two  forms— the  dry  and 
the  suppurative.  The  latter  variety  is  more  common.  In  dry  ostitis  the 
bone-cells  undergo  granular  metamorphosis,  and,  together  with  the  inor- 
ganic salts  of  this  tissue,  are  al)sorl)ed.  Suppuration,  if  present,  is  lim- 
ited, and  the  products  of  inflammation  undergo  fatty  degeneration.  In 
these  cases  the  breaking  down  of  the  bodies  of  the  vertebra?,  to  the  ex- 
tent of  marked  deformity,  may  occur  without  recognized  febrile  move- 
ment. In  the  suppurative  form  the  destructive  pi-ocess  is  more  rapid, 
and  is  accompanied  by  the  formation  of  a  variable  quantity  of  embryonic 
tissue,  the  bone  breaks  down  in  bulk,  and  particles  varying  in  size  aji- 
pear  in  the  pus  which  results  from  the  inflammatory  process.  The  ear- 
liest pathological  change  in  such  cases  is  in  the  cancellous  tissue  of  the 
body.  In  rarer  instances  the  lesion  commences  as  a  synovitis  in  the 
costo-vertebral  or  interarticular  joints,  whence  the  disease  may  invade 
the  intervertebral  disks  and  bodies.  Primary  inflammation  of  the  inter- 
vertebral tibro-cartilage  is  believed  to  be  very  rare.  As  the  destructive 
process  continues,  the  cancellous  tissue  of  the  body,  and  chiefly  of  the 
anterior  portions  of  the  column,  breaks  down  (Fig.  079),  causing  abnoimal 


FlQ.  679. — Destructive  ostitis 
of  the  anterior  portion  of 
the  bodies  ot  the  vertebrffl. 
(Alter  Noble  Smith.) 


Fio.  680. — The  same  process 
in  the  posterior  portion  of 
tlie  bodies  of  the  vertebne. 
(After  Noble  Smith.; 


Fio.  681. — Deformity  resultin? 
from  fracture  of  a  vertebra. 
(After  Noble  Smith.) 


curvature,  with  sharp  projection  of  the  spinous  proce.sses.  The  angular 
deformity  is  less  apt  to  be  present  wlieii  the  disease  attacks  the  posterior 
portion  of  the  body,  where  the  superincumbent  weight  in  great  part  falls 
upon  the  articular  processes  (Fig.  680). 

Symptoms. — The  clinical  history  of  Pott's  disease  may  be  divided 
into  two  stages :  The  first  stage  includes  all  the  phenomena  which  occur 
up  to  the  time  when  deformity  is  recognized  ;  the  seennd  stage  embraces 
all  the  changes  met  with  after  deformity.  The  usual  symptoms  of  the 
first  stage  are  pain  and  muscular  rigidity,  with  varying  exacerbations  ot 
temperature.  Pain  may  be  elicited  when  the  patient  assumes  the  erect 
posture,  by  direct  pressure  upon  the  spines  of  the  vertebrje  involved, 


SPONDYLITIS.  701 

and  by  concussion  of  the  column  transmitted  from  the  head  downward. 
VVlien  the  bodies  alone  are  involved  (the  usual  condition)  it  may  be  less- 
ened or  made  to  disappear  entirely  by  susi^ension  of  the  patient  from  a 
portion  of  the  column  al)ove  the  lesion  ;  by  bending  the  spine  backward, 
thus  throwing  the  weight  upon  the  healthy  articular  i)rocesses ;  or  by 
laying  the  patient  face  downward  across  the  surgeon's  lap,  and  making 
extension  by  sejjarating  the  knees. 

Muscular  rigidity  is  recognizable  in  a  majority  of  instances,  and  in 
children  may  be  observed  as  a  symptom  of  j^ain,  when  the  presence  of 
pain  is  denied.  Fixation  of  the  dorsal  muscles  is  evident  in  the  stiff 
and  unusual  manner  in  which  the  back  is  held  as  the  patient  moves 
about,  and  in  the  awkward  jiosture  assumed  while  sitting  down.  If 
directed  to  bend  the  vertebral  column,  as  in  stooping  to  pick  \\\)  some- 
thing from  the  floor,  the  movements  are  cautious  and  constrained,  alto- 
gether lacking  in  the  celerity  and  suppleness  which  are  seen  in  flexion 
and  extension  of  the  vertebral  column  in  health.  In  the  earlier  stages 
pain  is  dull  and  steady  in  character,  and  is  usually  local,  being  confined 
to  the  neighborhood  of  the  part  affected. 

Elevation  of  temperature  may  be  present  at  any  stage  of  Pott's  dis- 
ease. It  is,  as  a  rule,  the  index  of  the  extent  and  rapidity  of  the  inflam- 
matory and  destructive  processes.  The  thermometer  may  register  from 
the  normal  as  high  as  101°-102°  F.,  and  only  in  exceptional  instances  as 
high  as  104°.  In  a  fair  proportion  of  cases  in  the  early  stages,  and  esj^e- 
cially  in  the  dry  form  of  ostitis,  no  elevation  of  tem])erature  can  be 
detected. 

The  second  stage  of  the  disease,  that  of  deformity,  may  be  present  in 
the  course  of  a  few  weeks  after  the  appearance  of  the  first  stage,  or  sev- 
eral months  may  elapse.  All  of  the  symptoms  of  the  preceding  stage  are 
jjresent  in  the  second  stage  of  Pott's  disease.  If  proper  treatment  has 
not  been  instituted,  interference  with  the  functions  of  the  cord  at  and 
below  the  seat  of  lesion,  or  of  the  nerves  which  pass  out  between  the 
diseased  vertebrae,  is  apt  to  occur,  from  displacement  of  the  bones  or 
as  a  result  of  inflammatory  products  pressing  upon  the  spinal  cord  and 
nerves.  Paralysis  of  motion  and  sensation,  in  a  varying  degree,  occurs 
in  a  certain  i)roi)ortion  of  cases. 

When  deformity  occurs  the  convexity  of  the  curve  is  posterior  in 
about  95  per  cent  of  all  cases.  The  "knuckle"  may  consist  of  a  single 
sjjinous  process  (Fig.  328),  or  several  spines  may  project,  as  in  Fig.  670. 

The  degree  of  deformity  depends  upon  the  location  of  the  disease, 
its  extent,  and  in  part  to  genei-al  relaxation  of  the  erector  muscles.  It  is 
greater  when  the  lower  cervical  and  upper  dorsal  vertebrae  are  involved. 
The  formation  of  pus  and  the  resulting  abscess  and  sinuses  belong  chiefly 
to  the  last  stage  of  ostitis  of  the  si)ine.  The  abscess  may  travel  along 
the  psoas  muscle,  ojiening  near  the  middle  of  the  groin  above  or  beneath 
Poupart's  ligament,  the  pus  may  escape  through  the  inguinal  canal,  over 
the  iliac  crest,  or  through  the  sacro-sciatic  notch  :  or  it  may  be  arrested 
at  a  higher  point  and  escape  recognition,  unless  careful  examination  is 
made  under  ether  narcosis. 


702  A  TEXT-BOOK  ON  SURGERY. 

Spinal  abscess  is  usually  single,  occasionally  double.  "WTien  occur- 
ring in  the  ujiper  dorsal  region  it  may  be  arrested  by  the  diaphragm,  or 
pass  behind  this  into  the  slieath  or  fascia  of  the  psf)as  muscle.  Abscess 
in  ostitis  of  the  bodies  almost  always  travels  downward  on  one  or  the 
other  side  of  tlie  anterolateral  asj)ect  of  the  spine.  AVhen  the  articular 
processes  or  laminjp  are  involved,  the  pus  may  penetrate  the  dorsal  mus- 
cles and  point  posteriorly. 

In  occipito-cervical  or  upper  cervical  spondylitis,  the  pus  collection 
often  appears  at  the  posterior  wall  of  the  ])harynx  {refrophanjnf/cal 
abscess),  where  it  may  be  recognized  by  insijecfion  or  iligital  exploration. 
Interference  with  deglutition  and  phonation  is  not  infrequent.  The  con- 
tents of  an  abscess  resulting  from  destructive  ostitis  of  the  cervical  ver- 
tebne  may  also  descend  along  the  deep  fascia  of  the  neck  and  j)ass  into 
the  thorax  or  the  mediastinum.  In  this  manner  it  occasionally  linds  its 
way  into  the  jiericardium. 

Amyloid  changes  of  the  viscera  are  among  the  late  symptoms  of 
chronic  spondylitis. 

I)i(t(/)iosls. — In  general  the  recognition  of  the  disease  will  depend 
upon  a  histcn-y  in  accordance  with  most  of  the  symptoms  Just  detailed. 
As  to  the  portion  of  the  column  involved,  the  appreciation  of  localized 
pain  by  direct  or  indirect  pressure  is  an  indication  of  value.  When  the 
effei'ent  nerves  are  involved  by  pressure  from  the  i)roducts  of  inflamma- 
tion, certain  disturbances  in  their  course  or  distribution  are  of  diagnostic 
importance.  Spasm  of  the  larynx,  jjharynx,  diaphragm,  pain  down  the 
arm,  etc.,  naturally  attract  attention  to  the  points  of  exit  of  the  nerves 
supplying  these  parts.  When  tenderness  in  the  region  of  the  psoas 
muscles  is  evidenced  by  habitual  indisposition  to  extend  the  thighs, 
lumbar  ostitis  may  be  suspected.  When  the  gibbosity  is  recognized, 
a  diagnosis  is  no  longer  doubtfid.  The  early  recognition  of  abscess 
in  the  abdominal  region  is  possible  only  by  palpation  under  profound 
narcosis. 

K  the  articular  processes  are  diseased,  bending  of  the  sjainal  column 
backward  will  increase  the  pain.  Placing  the  patient  on  the  abdomen, 
with  the  head  and  lower  extremities  depressed,  will  diminish  it.  When 
the  bodies  and  intervertebi'al  disks  are  involved,  bending  the  spine  back- 
ward will  relieve  the  pressure  symptoms. 

Treatment. — In  the  mechanical  treatment  the  indications  are  to  se- 
cure fixation  of  the  spinal  column  in  the  position  of  least  discomfort 
to  the  patient.  Judicious  medication,  good  food,  and  pure  air  are  the 
indications  in  the  constitutional  treatment.  The  character  of  the  mech- 
anism to  be  used  will  dei)end  in  good  part  upon  the  portion  of  the 
vertebral  column  involved.  It  is  essential,  in  order  that  any  apparatus 
may  fully  meet  the  indications,  that  not  only  shall  the  diseased  bones 
and  the  healthy  tissues  be  held  laractically  immovable,  but  the  sujjer- 
incumbent  weight  must  in  whole  or  part  be  lifted.  Fixation  may  be 
accomplished  by  any  form  of  well-adjusted  apparatus,  but  lifting  the 
weight  of  the  body,  which  is  above  the  seat  of  disease,  is  a  more  difficult 
undertaking. 


SPONDYLITIS. 


703 


The  downward  pressure  upon  the  bodies  when,  as  is  usual,  these 
structures  are  involved  and  breaking  down,  can  be  in  great  part  obviated 
by  extension  or  backward  bending  of  the  spine,  in  which  mananivre  the 
pressure  is  transferred  from  the  bodies  and  intervertebral  disks  to  the 
articular  processes  and  pedicles. 

Much  of  the  api^aratus  devised  for  the  arrest  and  cure  of  Pott's  dis- 
ease is  based  upon  this  principle.  Another  method  is  based  upon  the 
principle  of  lifting  the  parts  above  the  seat  of  the  lesion,  and  removing 
the  pressure  in  a  greater  or  less  degree  not  only  from  the  bodies  but  also 
from  the  articular  ijrocesses  (extension  and  counter-extension,  or  sus- 
pension). 

To  accomplish  the  former  the  spinal  braces  of  Drs.  Davis,  Taylor, 
and  Shaffer  have  been  constructed.  For  complete  extension  or  lifting,  the 
plaster-of-Paris  jacket  or  the  jury-mast  of  Prof.  Sayre,  and  the  suspen- 
sion-carriage of  Dr.  Meigs  Case,  more  nearly  meet  all  the  indications. 

In  appropriate  cases  each  of  these  forms  of  apparatus,  if  properly 
adjusted  and  intelligently  worn,  will  accomplish  all  that  is  possible  in 
the  mechanical  treatment  of  Pott's  disease.  Much  of  the  discredit  which 
is  brought  ui:)on  particular  apparatus  can  justly  be  charged  to  the  lack 
of  judgment  in  the  selection  of  cases,  want  of  skill  in  the  adjustment  of 
the  instrument,  and  failure  on  the  part  of  the  attendant  or  patient  in 
persisting  in  its  use  a  sufficient  length  of  time. 

The  selection  of  the  apparatus  best  adapted  to  succeed  will  depend 
upon  the  location  of  the  disease  and  the  age  and  conformation  of  the 
patient.     Clinically  the  spinal  column  is  divisible  into  three  regions: 
1,  embracing  the  occipito-cervical  • 
articulation,  the  cervical  vertebrje, 
and  down  to  the  third  dorsal ;  2, 
fi'om  the  third  to  the  tenth  dorsal ; 
3,    from   the   tenth   dorsal   to   the 
sacro-lumbar  articulation. 

The  lower  region  is  more  amen- 
able to  treatment,  the  upper  next, 
while  the  middle  region,  which  is 
most  frequently  involved  in  osti- 
tis, is  the  most  difficult  to  man- 
age. 

Third  Region. — In  the  mechan- 
ical treatment  of  Pott's  disease  in 
the  third  region,  Sayre's  plaster- 
of-Paris  jacket,  of  light  make  and 
properly  adjusted,  is  preferable. 
In  its  application  the  following 
articles  are  essential :  1,  a  suspen- 
sion apparatus  :  2,  a  tight-fitting,  ^'°-  682 -Suspension  apparatus  fnr  applying  plas- 
'^ '^  '       '  o     "  ""^""n^  ter-ol-Puns  jacket.     ^ After  Sayre.) 

seamless,  knit  shirt ;   3,  plaster-of- 

Paris  bandages.     The  suspension  apparatus  of  Reynders  &  Co.  (Fig. 

(382)  gives  perfect  satisfaction.     It  consists  of  an  iron  cross-bar  from 


704 


A  TEXT-BOOK  ON   SURGERY. 


which  are  suspended  padded  loops  for  each  axilla,  and  acliin  and  occi- 
put swing  for  lifting  from  tlK^se  points.  The  crows-bar  is  attached  at 
its  center  to  a  block  and  pulley.  After  the  knit  shirt  is  a])plied,  the 
arms  of  the  patient  are  slipped  through  the  padded  loojjs,  while  the  col- 
lar is  buckled  around  beneath  the  chin  and  occiput.  The  center  and 
lateral  suspension-straps  shoidd  be  adjusted  so  that  when  the  lift  is 
made  the  tension  will  be  equally  distributed.  The  block  of  the  jjulley 
apparatus  may  be  fastened  to  a  hook  in  the  ceiling  or  to  the  tripod  (Fig. 
683).     The  plaster  bandages — the  method  of  preparing  which  is  given  on 


Fio.  G83.— Suspension  apparatus  and  tripod  in  position  for  lifting.     (After  Sayre.) 


page  10 — should  be  perfectly  fresh  and  well  made,  for  a  good  deal  of  suc- 
cess depends  upon  the  quality  f>f  the  gypsum  and  the  thoroughness  with 
which  it  is  worked  into  the  meshes  of  the  crinoline.  As  the  direction  for 
applying  this  jacket,  as  given  by  Prof.  Sayre — to  whom  the  profession  is 
indebted  for  bringing  it  so  prominently  into  use — can  not  be  improved 
upon,  I  give  it  in  his  language : 

"Before  applying  the  plaster  bandage,  I  place  over  the  abdomen,  be- 
tween the  shirt  and  the  skin,  a  pad  composed  of  a  towel  folded  up  so  as 
to  form  a  wedge-shaped  mass,  the  thin  edge  being  directed  downward. 


SPONDYLITIS.  705 

This  is  intended  to  leave  room,  when  removed,  for  the  expansion  of  the 
abdomen  after  meals,  and  so  I  call  it  the  'dinner-pad.'  It  is  important 
to  make  it  thin  where  it  comes  under  the  lower  edge  of  the  jacket,  or  else 
the  jacket  would  tit  too  loosely  about  the  lower  part  of  the  abdomen.  It 
should  be  taken  out  just  before  the  plaster  sets.  It  is  always  a  good  plan 
to  get  the  patient  to  eat  a  hearty  meal  before  the  jacket  is  applied,  but 
this  precaution  of  allowing  room  for  meals  should  never  be  neglected. 

"  If  there  are  any  very  prominent  spinous  processes  which,  at  the  same 
time,  may  have  become  intiaraed  in  consequence  of  pressure  produced  by 
instruments  previously  worn,  or  from  lying  in  bed,  such  places  should  be 
guarded  by  little  i^ads  of  cotton  or  cloth,  or  little  gloA'e-fingers  tilled  with 
wool  placed  on  either  side  of  them.  Another  detail,  which  I  have  found 
to  be  of  practical  value  in  some  cases,  is  the  application  under  the  shirt, 
over  each  anterior  iliac  spine,  of  two  or  three  thicknesses  of  folded  cloth 
three  or  four  inches  in  length.  If  these  little  pads  be  removed  just  be- 
fore the  jilaster  has  completely  set,  such  bony  processes  will  be  left  free 
from  pressure. 

' '  If  the  patient  be  a  female,  and  especially  if  she  be  developing  at  the 
time,  it  will  be  necessary  to  apply  a  pad  iinder  the  shirt  over  each  breast 
before  the  jslaster  bandage  is  put  on.  These  jiads  should  be  removed  just 
before  the  plaster  sets,  and  at  the  same  time  slight  pressure  should  be 
made  over  the  sternum  for  the  purpose  of  indenting  the  central  portion 
of  the  plaster  jacket,  and  of  thus  giving  form  to  the  body,  and  of  remov- 
ing pressure  from  the  breasts. 

"The  skin-fitting  shirt  having  been  tied  over  the  shoulders,  and  then 
pulled  down,  and  kept  stretched  by  means  of  tapes  applied,  one  in  front, 
the  other  behind,  near  its  lower  edge,  and  tied  tightly  over  a  handker- 
chief placed  on  the  perinjeum,  the  patient  is  to  be  gently  and  slowly 
drawn  up  by  means  of  the  apparatus  until  he  feels  perfectly  comfortable, 
and  never  beyond  that  point,  and  while  he  is  retained  in  this  position  the 
plaster  bandage  is  to  be  applied.  A  prepared  and  saturated  roller,  w^liich 
has  been  gently  squeezed  to  remove  all  surplus  water,  is  now  applied 
around  the  smallest  part  of  the  body,  and  is  carried  around  and  around 
tlie  trunk  downward  to  the  crest  of  the  ilium,  and  a  little  beyond  it,  and 
afterward  from  below  upward  in  a  spiral  direction,  until  the  entire  trunk 
from  the  pelvis  to  the  axillje  has  been  incased.  The  bandage  should  be 
placed  smoothly  around  the  body,  not  drawn  too  tight,  and  especial  care 
taken  not  to  have  any  single  turn  of  the  bandage  tighter  than  the  rest. 
Each  layer  of  bandage  should  be  rubbed  most  thoroughly  with  the  hand 
by  an  assistant,  that  the  plaster  may  be  closely  incorporated  in  the  meshes 
of  the  crinoline,  and  bind  together  the  various  bandages  which  make  up 
the  jacket,  thus  making  it  much  stronger  than  if  attention  is  not  paid  to 
this  particular.  If  you  notice  any  spot  which  seems  weak  or  likely  to 
give  way,  pass  the  bandage  over  it,  and  then  fold  it  back  on  itself,  and 
do  this  until  you  have  placed  several  tliicknesses  of  bandage  over  this 
point,  being  careful  to  wet  all  well  together,  and  then  pass  a  turn  com- 
pletely around  the  trunk  to  retain  any  ends  which  might  have  a  tendency 
to  become  detached. 
45 


706  A  TEXT-BOOK   ON  SURGERY. 

"In  ;i  very  sliort  time  tin-  phistcr  sets  with  sufRcient  firmness,  so  that 
the  patient  can  be  removed  from  the  suspending  apparatus,  and  laid 
upon  his  face  or  back  on  a  hair  mattress,  or — what  is  preferalde,  es])e- 
cially  wiieii  there  is  much  ju-ojection  of  the  spinous  processes  or  sternum 
— an  air-bed.  Before  the  phister  has  completely  set,  the  dinner-pad  is  to 
be  removed,  and  the  plaster  gently  pressed  in  with  the  hand  in  frt)nt  of 
each  iliac  spinous  process,  for  the  purpose  of  widening  the  jacket  over 
the  bony  projections.  In  the  case  of  a  young  child  with  a  small  pelvis 
it  may  liappen  that  the  circumference  of  the  body  at  the  umliilicus  is  as 
great  as  around  the  pelvis,  but,  as  the  soft  parts  in  the  ]und)ar  region 
allow  us  to  mold  the  plaster  as  we  choose,  you  can  still  obtain  a  i)oint  of 
support  at  the  pelvis  ;  if,  as  the  jacket  hardens,  you  will  press  it  in  at 
the  sides  above  the  ilium,  and  in  front  and  rear  above  the  pubes,  the  an- 
tero-posterior  diameter  above  will  be  the  longer,  while  below  it  will  be 
the  transverse  one.'' 

When  the  angular  projection  is  extreme,  or  when  an  ulcer  exists,  it 
will  be  advisable  to  cut  a  hole  in  the  jacket  at  this  point,  large  enough  to 
prevent  any  undue  pressure.  In  case  of  abscess,  a  window  of  sufficient 
size  to  allow  free  drainage,  and  a  frequent  change  of  dressing,  should  be 
made. 

The  commendable  features  of  this  plan  of  treatment  are  the  extension 
obtained  by  suspension,  fixation  by  the  plaster  while  in  the  most  favor- 
able position,  and  the  cheapness  and  readiness  with  which  it  may  be  em- 
ployed. 

The  objections  are,  uncleanliness  by  reason  of  the  immovable  nature 
of  the  apparatus,  and  the  excoriations  which  are  a  cause  of  considerable 
comidaint.  The  first  objection  may  be  met  by  splitting  the  corset  down 
in  front,  and  reapplying  it  while  the  patient  is  suspended,  and  making  it 
tight  by  a  roller  carried  around  the  body  several  times.  As  for  excoria- 
tions, it  may  be  said  that  no  apparatus  which  grasps  the  body  tight 
enough  to  secure  fixation  is  free  from  this  danger.  When  they  occur 
with  the  plaster  jacket,  the  fault  generally  lies  either  in  the  im])roper 
manner  of  its  application  or  carelessness  on  the  part  of  tlie  attendant. 

Second  Rer/ ion. — When  the  middle  or  dorsal  region  is  involved,  the 
plaster  jacket  is  not  so  serviceable  as  in  ostitis  of  the  vertebra^  in  the 
lower  region  of  the  spine,  altliough  much  good  will  be  accom])lished  by 
the  partial  fixation  of  the  thorax  as  high  as  to  the  level  of  the  axillge. 
The  efficacy  of  this  method  diminishes  the  higher  the  diseased  process 
is  located,  and,  when  the  lesion  invades  the  sixth  dorsal,  or  above  this 
point,  the  jacket  without  head-suspension  is  almost  useless.  In  all  cases 
of  Pott's  disease  above  the  tenth  dorsal,  suspension  of  the  head  is  an 
essential  feature  of  treatment.  A  favorable  result  would  be  achieved  in 
a  greater  proportion  of  cases  if  this  point  were  insisted  upon,  and  the 
prejudice  against  the  suspension  apparatus  overcome. 

In  its  application  the  patient  should  be  suspended  as  just  described, 
and  a  plaster  jacket  applied,  from  just  above  the  trochanters  up  as  high 
as  the  axilliP.  After  two  layers  of  the  plaster  bandages  have  been  ap- 
plied, the  jury-mast  is  adjusted,  and  its  framework  covered  in  with  the 


SPONDYLITIS. 


70^ 


suceeeding  layers  of  bandage.  The  jury-mast  (Fig.  684)  consists  of  a 
back-piece,  in  shape  not  unlike  the  inverted  letter  U,  made  of  soft  ii-on, 
which  enables  it  to  be  accurately  molded  to  lit  the  surface  to  which  it  is 
applied.  To  this  are  fastened  two  or  three  strips  of  tin,  made  rough  liy 
a  series  of  perforations  with  an  awl.  To  the  upper  end  of  the  back-piece 
a  curved  bar  of  light  steel  is  attached,  in  such  a  manner  that  it  can  be 
raised  or  depressed  at  will.  At  the  end  of  this  crane  is  a  light  cross-])ar, 
hooked  at  each  extremity,  from  which  the  collar  is  suspended.  After 
the  first  two  layers  of  plaster  bandages  have  hardened,  the  apparatus  is 
])ent  to  fit  the  surface  of  the  back,  and  is  adjusted  to  the  jacket,  with 
the  middle-piece  or  crane  exactly  in  the  median  line  of  the  back  of 
the  neck  and  occiput,  and  its  extremity  over  the  center  of  the  top  of 
the  head,  so  that  traction  by  the  strips  will  be  directly  upward.     It  is 


^rr 


Fio.  684. — Sayre's  jury-mast  head-swing. 
'( After  Say  re.) 


F:g. 


685. — Jury-mast  apparatus  applied. 
(After  Sayre.) 


fastened  by  carrying  plaster  rollers  over  the  tin  strips  and  back-piece, 
and  working  in  plaster-mortar.  "When  the  plaster  hardens  the  apparatus 
is  immovably  incorporated  into  the  jacket.  The  suspension-collar  shoidd 
now  ])e  buckled  beneath  the  occipital  protuberance,  and  the  strips  tight- 
ened enough  to  lift  the  weight  of  the  head  from  the  neck.  The  jacket 
may  be  couA^erted  into  a  movable  corset,  by  splitting  it  along  the  middle 
line  in  front  and  attaching  hooks  for  lacing  (Fig.  68^).  If  the  jury-mast 
can  not  be  applied,  in  ostitis  involving  the  vertebrjB  between  the  third 
and  ninth  dorsal,  Shaffer's  modification  of  Taylor's  brace  should  be  pre- 
ferred. 

"  It  consists  (Fig.  686)  of  the  pelvic  band,  A,  to  which  are  riveted  two 
perfectly  plain  uprights,  B  B,  of  annealed  bar-steel,  which  uprights  ex- 
tend to  the  shoulder-pieces,  D  D,  and  are  steadied  at  a  point  opposite 


708 


A   TEXT-BOOK   ON    SURGERY. 


the  scapuljB  by  tlie  cross-pieces,  E  E.  The  pads  at  CC  are  simple  rolls 
of  Canton  tiannel  stitched  to  the  uprights  by  transverse  threads,  shown 
in  the  eni^ravinc:.  P  represents  the  location  <»f  the  deformity,  and 
F F F F  shows  the  plaster  zcme  securing  the  uprights  in  lirni  contact 
with  the  tissues  Ij'ing  over  the  transverse  processes. 

"  Fig.  687  illustrates  the  anterior  appearance  of  tlu'  ai)inu"itus.  F  F 
are  the  shoulder-strai)s,  passing  from  the  ends  of  the  shoulder-pieces, 
D  D  (Fig.  686),  to  the  buckles,  H H  (Fig.  686).  J"  is  a  piece  of  padded 
webliing  crossing  the  anterior  and  superior  wall  of  the  tlifmix.  It  is 
secured  -oX  G  G  (Fig.  686).     L  is  also  a  piece  of  padded  webbing,  which 


Fio. 


686.— Shaffer's  apparatus. 
(Alter  Shaffer.) 


Fio.  087.- 


■Front  view  of  Shaffer's  apparatus. 
(Aaer  Shaffer.) 


completes  the  circumference  of  the  pelvis  by  fastening  at  the  biickles 
attached  to  the  pelvic  band  A  (Fig.  686).  K  represents  the  anterior  ap- 
pearance of  the  plaster  zone. 

"  At  Z>  D  (Fig.  686)  and  at  8S  (Fig.  687)  are  the  shoulder-pieces,  which 
prevent  pressure  and  serve  as  points  of  attachment  for  the  axillary  straps, 
so  that  these  axUlary  straps,  in  i)assing  over  the  shoulders,  shall  not 
exert  undue  downward  pressure.  Being  annealed,  these  shoulder- pieces 
may  be  bent  in  any  direction  desired  ;  and  they  should  lie  curved  so  that 
a  very  little  sjpace  exists  between  them  and  the  subjacent  parts.     The 


SPONDYLITIS.  709 

pelvic  base  forms  a  sufficient  support  for  tlie  apparatus,  and  it  becomes 
quite  frequently  necessary  to  apply  perineal  pads  to  prevent  the  moving 
upward  of  the  apparatus,  rather  than  to  adjust  shoulder-pieces  to  keep 
the  appliance  from  slipping  down. 

"To  prepare  and  adjust  the  apparatus:  1.  Take  two  light  bars  of 
annealed  steel,  of  a  length  which  corresponds  to  the  distance  between  the 
commencement  of  the  anal  commissure  and  the  spinous  process  of  the 
second  dorsal  vertebrae.  These  fomi  the  uprights.  2.  A  piece  of  sheet- 
steel,  about  one  inch  wide  and  long  enough  to  reach  from  the  top  of  one 
trochanter  major  to  the  other  ;  bend  it  to  coiTespond  with  the  transverse 
sacro-iliac  region,  and  cover  with  chamois  or  other  soft  material.  This 
forms  the  hip-band.  3.  Two  cross-pieces,  four  or  five  inches  long,  which 
are  riveted  to  the  uprights  at  points  which  correspond  to  the  lower  border 
of  the  axilla  and  the  inferior  angle  of  the  scapula.  4.  Two  small  pieces 
of  light  bar-steel,  about  two  and  a  half  inches  long,  which  are  covered 
and  riveted  to  the  upper  end  of  the  uprights,  at  an  angle  of  about  45°, 
and  bent  as  shown  in  the  engraving.  Buckles  are  now  attached  to  the 
ends  of  the  shonlder-pieces,  the  cross-pieces,  and  the  pelvic  band.  The 
distance  between  the  uprights  should  be  aliout  one  inch  and  a  quarter,  or 
sufficient  to  avoid  any  pressure  upon  the  spinous  processes.  These  com- 
ponent parts  being  riveted  together,  two  rolls  of  Canton  flannel,  about 
three  eighths  of  an  inch  thick,  and  a  little  wider  than  the  upright  bar, 
are  now  prepared.  They  should  reach  from  about  one  inch  above  the 
pelvic  band  to  the  lower  cross-piece.  Two  broad  webbing-bands,  as  shown 
at  /  and  L  (Fig.  687),  are  then  made  ready.* 

"  The  patient  is  placed  upon  two  tables  of  equal  height,  and  the  tables 
are  then  separated  so  that  the  parts  selected  for  the  zone  may  be  freely 
accessible  from  all  sides.  One  assistant  grasps  the  ])atient  under  the 
axillfe,  the  other  makes  steady  but  easy  traction  at  the  thighs.  While  the 
patient  is  in  this  prone  position,  the  operator  fits  the  uprights  to  the  line 
of  the  transverse  processes  ;  in  other  words,  adjusts  the  apparatus  to  the 
defoimity.  A  pair  of  'monkey-wrenches'  may  be  easily  used  as  a  pair 
of  levers  with  which  to  bend  the  annealed  steel  uprights  into  any  jiosition. 
It  takes  but  a  few  moments  to  adapt  the  uprights  to  the  deformity.  In 
the  mean  time  the  patient  is  quiet.  He  does  not  struggle  nor  cry.  The 
traction  is  affording  relief,  and  is  not  producing  any  injury.  ^Vhile  ho 
lies  quietly,  and  the  Canton  flannel  pads  are  sewed  on,  we  pass  a  piece  of 
Canton  flannel,  or  merino  gauze,  around  the  body  over  the  projection. 
Then,  the  plaster  bandages  and  everything  being  in  readiness,  the  apjia- 
ratus  is  laid  on  the  back  accurately,  traction  is  steadily  maintained,  the 
thoracic  and  pelvic  straps  are  fastened,  and  the  jtlaster  zone  is  snugly 
applied.     The  axillary  straps  are  left  until  the  plaster  is  hardened,  and 

*  •'  Messrs.  Tieraann  &  Co.,  No.  67  Cliatlinm  Street,  New  York,  will  furnish  tliis  apparatus 
at  a  cost  of  from  five  to  seven  dollars,  according  to  size.  It  would  also  be  well,  in  sending  tlio 
mcasureiuents,  to  inclose  an  outline  of  the  spinal  column,  from  the  spinous  process  of  the  second 
dorsal  down.  This  may  be  done  by  idacing  a  strip  of  lead  along  the  spinous  processes,  and 
molding  it  accurately  to  the  outline  |>resented.  Ky  transferring  this  lead  carefully  to  a  sheet  of 
paper,  .an  accurate  protile  of  the  spine  may  be  obtained  with  a  lead-pencil  tracing. 


710 


A  TEXT-BOOK   ON   SURGERY. 


the  patient  is  ready  to  sit  up. 
When  the  operation  is  complete, 
the  patient  is  finnly  secured  in 
an  apparatus  which  affords  a  stip- 
port  that  can  be  maintained  by 
the  thoracic,  axiUary,  and  pelvic 
straps,  and  the  uitrights  are  held, 
without  undue  pressure,  in  their 
position  by  the  plaster  zone."* 

The  value  of  this  apparatus 
consists  in  the  fair  degree  of  hxa- 
tion  which  it  secures,  but  chiefly  in 
the  dorsal  spine  is  extended,  that 


Fig.  689. — Dr.  Meig-.  Case's  suspension-carriage,  for  both  tbe 
standing  and  sitting  postures. 


Flo.  688. — Extension  in  tbe  recumbent  posture. 
(After  Reeves.) 

the  fact  that,  when  properly  applied, 
is,  bent  backward  to  such  a  degree 
that  the  weight  from 
above  is  removed  from 
the  diseased  bodies  and 
transferred  to  the  sound 
articular  processes  and 
pedicles.  If  this  posi- 
tion is  properly  main- 
tained, relief  will  usual- 
ly follow  in  those  cases 
where  the  bodies  alone 
are  involved.  Instead 
of  the  plaster  zone,  a 
broad  canvas  or  soft 
leather  belt  may  be  used. 
First  Region. — In 
ostitis  of  the  vertebral 
column,  from  the  third 
dorsal  to  the  occipito- 
atloid  articulatirm,  the 
treatment  should  be  by 
sitspension  from  the  chin 
and  occiput.  In  accom- 
plishing this  end  the 
jury-mast,  applied  and 
worn  as  just  described, 
is  entitled  to  the  first  con- 
sideration. Much  good 
may  be  obtained  from 
the  judicious  use  of  ex- 
tension in  the  recumbent 
posture  (Fig.  688).  This 
apparatus  may  be  worn 
at  night,  when  the  head- 


•  "Pott's  Disease,"  etc.,  N.  M.  Sbatler,  M.  D.     (i.  T.  Putnam's  Sons,  New  York,  1879. 


SPINA   BIFIDA. 


■11 


stall  of  jury-mast  is  removed.  la  the  worst  class  of  cases  it  is  advisable 
to  employ  the  extension  in  bed  until  the  symptoms  of  paralysis  are 
relieved.  Instead  of  the  block  and  pulley,  with  weight,  the  extension 
may  be  made  by  elastic  bands  attached  to  the  chin-and-occiput  collar 
and  the  head  of  the  bed,  while,  if  necessary,  fixation  may  be  secured 
by  elevating  the  head  of  the  bed  six  or  eight  inches. 

The  suspension-carriage  of  Dr.  Meigs  Case,  which  lifts  from  the  axillfe, 
chin,  and  occiput  (Fig.  689),  is  a  valuable  apparatus  in  the  treatment  of 
Pott's  disease  in  tlie  cervical  and  upper  dorsal  region.  If  the  degree  of 
elastic  susi^ension  from  the  chin  and  occiput  which  it  affords  during  the 
waking  hours  is  continued  during  sleep,  by  the  method  of  extension  in 
the  recuml>ent  posture  above  given,  success  would  be  achieved  in  the 
majority  of  cases.  It  is  chiefiy  objectionable  by  reason  of  its  high 
price,  which  places  it  beyond  the  reach  of  many  who  can  obtain  the 
jury-mast. 

The  successful  management  of  Pott's  disease  depends  not  (mly  upon  a 
thorough  practical  knowledge  of  the  construction  and  application  of  the 
mechanical  apparatus  required,  but  upon  the  careful  and  constant  atten- 
tion of  a  competent  surgeon  during  the  entire  time,  from  the  incipiency 
of  the  spondylitis  until  several  months  have  elapsed  after  consolidation 
is  effected.  The  prevention  of  chafing  and  sores,  the  opening  and  drain- 
age of  abscesses,  the  renewal  or  tightening  of  the  apparatus,  require  just 
as  much  skill  as  in  the  diagnosis  and  first  adjustment  of  the  mechanism. 
As  regards  abscess  in  ostitis  of  the  vertebral  column,  it  may  be  said  that 
incision  and  drainage  are  generally  indicated,  whether  occurring  on  the 
back,  in  the  way  of  the  apparatus,  or  pointing  near  the  groin  (p.soas 
abscess).  Fresh  air,  well-selected  articles  of  food,  and  tonics,  are  essen- 
tial. In  the  severer  cases,  in  wliich  a  myelitis  is  developed  from  compres- 
sion by  the  products  of 
inflammation,  potassium 
iodide,  in  full  and  contin- 
ued doses,  is  reconuneud- 
ed  by  Professor  Gibney. 
In  all  cases  where  the  re- 
cumbent posture  is  as- 
sumed, an  effort  should 
be  made  to  keep  the  pa- 
tient on  the  back,  with  a  pillow  so  arranged  that  the  s])inal  column  is 
bent  well  backward,  and  the  pressure  on  the  bodies  in  this  way  partially 
relieved.  The  suspensory  cradle  of  Reeves  (Fig.  690)  will  accomplish 
this  end  more  successfully.  A  splint  or  shell  is  made  of  gutta-percha  or 
sole-leather,  and  molded  accurately  to  the  back,  from  the  sacrum  to  the 
neck.  With  this  held  in  position  by  a  roller,  the  patient,  while  lying 
down,  is  supported  by  the  swing,  as  shown  in  Fig.  690. 

Spina  Bifida. — This  condition  results  from  a  failure  of  development 
in  the  laminae  and  spines  of  one  or  more  of  the  vertebrae.  Through  the 
opening  left  by  this  incomplete  closure  of  the  bony  canal  the  membranes 
of  the  cord  are  protruded,  forming  a  sac  of  variable  size,  which  is  dis- 


Fio.  690. — Reeres's  suspensorr  cradle.     (.Vfter  Reeves.) 


712  ATFA'T-BOOK   ON     SURGERY. 

tended  by  the  cerebro-spinal  fluid.  'Hie  cord  itself  may  be  wholly  or  in 
part  Hjjread  out,  and  roTni)rt'.ssed  a,ii:ai:ist  tlie  saf. 

Spina  bifida  is  met  with  most  frequently  in  the  lumbosacral  re- 
gion, next  in  frequency  in  the  neck,  rarely  elsewhere.  One  tissuie  may 
exist  l)elow  and  one  above  in  the  same  child,  though  it  is  very  rarely 
multiple. 

The  tumor  may  vary  in  size  from  one  inch  to  six  or  eight  inches  in  the 
longest  diameter,  and  may  be  sessile  or  pedunculated.  It  is  elastic  to  tlie 
touch,  and  is  usually  covered  by  the  integument,  which  is  thinner  than 
normal.  In  some  instances  the  skin  is  wanting  over  the  mass,  the  pro- 
truding dura  mater  forming  the  outside  covering  of  the  mass. 

The  character  of  the  swelling  may  be  recognized  by  its  congenital 
origin,  its  location  in  the  median  line  of  the  back,  almost  always  in  the 
lumbo-sacral  region,  its  smooth  contour,  elasticity,  and  chiefly  by  its 
variable  size.  It  becomes  larger  and  more  tense  during  the  act  of  crying, 
and  liy  pressure  its  contents  may  in  part  be  forced  back  into  the  sjjinal 
cord  and  ventricles  of  the  brain.  Convulsive  movements  may  follow  too 
great  and  prolonged  compression  of  the  tumor.  The  prognosis  is,  as  a 
rule,  very  unfavorable.  Ulceration  of  the  integument  over  the  mass,  fol- 
lowed by  rupture  of  the  sac,  is  apt  to  occur,  usually  ending  in  death.  A 
recovery  after  this  accident  is  rare,  although  such  cases  are  reportt^l. 
Or  the  tumor  may  remain  indelinitely  in  about  the  same  condition  as 
at  birth.  Paralysis,  more  or  less  complete,  in  the  lower  extremitie.s,  is 
the  rule. 

The  palliative  treatment  of  spina  bifida  consists  in  the  application  of 
moderate  compression  over  the  tumor,  at  the  same  time  protecting  the 
integument  from  all  irritation  and  injury.  This  plan  of  treatment  should 
be  followed  out  for  one  or  two  years,  unless  more  radical  measures  are 
indicated  by  the  failure  of  this  method  to  arrest  or  greatly  retard  the 
growth  of  the  swelling.  When  the  tumor  is  suddenly  increased  in  size 
and  tension,  temporary  benefit  may  be  obtained  by  drawing  off  a  small 
quantity  of  the  fluid.  From  3  j  to  3  j  may  be  withdrawn  by  the  aspira- 
tor. The  smallest  needle  should  be  employed,  and  the  contents  slowly 
evacuated.  The  quantity  of  fluid  to  be  removed  will  vary  with  the  size 
and  tension  of  the  tumor,  and  the  effect  produced  by  the  asj)ii'ation.  Two 
or  three  drachms  w-ill  usually  suffice.  The  operation  may  be  repeated  as 
often  as  the  symptoms  demand.  It  is  advisable  to  intr.jduce  the  needle 
through  the  side  of  the  tumor  rather  than  in  the  middle  line.  In  sjjina 
bifida  when  the  tumor  is  well  pedunculated  and  the  communication  be- 
tween the  sac  and  membranes  of  the  cord  is  not  large,  a  cure  may  be 
effected  by  the  method  of  Morton,  which  consists  in  the  injection  of  the 
following  solution  :  iodine,  grs.  x  ;  iodide  of  potassium,  grs.  xxx  ;  glycer- 
ine, 3J.  From  §ss  to  3J  or  more  of  the  fluid  is  withdrawn  from  the 
sac,  and  from  3  ss.  to  3  iij  of  the  iodine  solution  injected,  and  the  punct- 
ure covered  with  collodion.  This  operation  may  be  repeated  if  necessary. 
\Vhen  the  communication  between  the  sac  and  the  spinal  cord  is  wide, 
and  the  tumor  is  sessile,  operative  interference  is  not  indicated. 


DEFORMITIES  OF  THE   LOWER  EXTREMITY.  713 


DBFORMrriES    OF  THE   LOWER   EXTREMITY. 

The  deformities  of  the  lower  extremity  may  be  divided  into  those — 
],  of  the  coxo-femoral  region;  2,  of  the  shaft  of  the  femur  in  its  en- 
tirety ;  3,  of  the  condyles ;  4,  of  the  tibia  and  fibula  ;  5,  of  the  tarsus 
and  metatarsus  ;  and,  6,  of  the  phalanges. 

In  this  classification,  distortions  of  the  pehis,  such  as  in  malacosteon 
and  rachitis,  are  excluded,  since  they  concern  the  obstetrician  rather  than 
the  surgeon. 

At  the  hip  there  may  exist  preternatural  mobility,  or  partial  or  com- 
plete immobility  with  malposition.  Preternatural  mobility  may  be  due 
to  the  following  causes  :  Arrest  of  development  in  the  bones  which  form 
the  acetabulum ;  congenital  failure  of  development  of  the  head  of  the 
femur,  or  atrophy  of  this  portion  ;  to  both  of  these  conditions  combined  : 
abnormal  length  of  the  capsular  ligament,  and  absence  of  the  ligamen- 
tum  teres. 

Immol)ility  with  malposition  results  from  inflammation  of  the  joint 
and  anchylosis,  with  or  without  destructive  ostitis  and  loss  of  substance. 
Contraction  of  the  psoas  and  iliacus  or  other  muscles  about  the  hip 
which  are  not  overcome  before  anchylosis  ensues  is  the  chief  cause  of 
deformity.  Dislocation  with  failure  at  reduction  always  induces  de- 
formity, and  the  same  is  true  of  fracture  when  not  properly  treated. 

In  preternatural  mobility  at  the  hip-joint  (congenital  dislocation)  the 
symjitoms  are  chiefly  a  peculiar  rolling  gait,  or  oscillation  to  right  and 
left  in  the  act  of  walking,  especially  when  the  deformity  is  bilateral. 
While  standing  erect,  the  trochanters  will  be  closer  to  the  iliac  crest 
than  normal,  which  condition  can  be  acciirately  determined  by  Nela- 
ton's  or  Bryant's  test.  In  these  cases  the  anterior  convexity  of  the  curve 
in  the  lumbar  region  is  exaggerated,  giving  the  patient  a  sway-back  ap- 
pearance. If  extension  is  made  from  the  feet,  while  the  trunk  is  fixed 
in  the  recumbent  posture,  the  length  of  the  patient  will  lie  considerably 
increased  over  that  measured  in  the  erect  position.  Absence  of  the 
head  of  the  femur  may  be  determined  liy  palpation  with  outward  rota- 
tion. Perforation  of  the  acetabulum  may  also  be  made  out  by  digital 
exploration  per  rectum. 

Treatment. — Locomotion  in  some  cases  may  be  much  improved  by 
persistent  effort  on  the  part  of  the  patient  to  train  the  muscles  to  hold 
the  femur  well  up  in  the  acetabulum  in  the  act  of  walking.  In  this  man- 
ner the  rolling  character  of  gait  may  be  in  great  part  corrected.  One  im- 
portant indication  in  the  treatment  of  these  cases  in  children  is  to  keep 
the  head  of  the  femur  from  too  great  pressure  against  the  soft  structures 
placed  in  the  bottom  of  the  cavity  of  the  acetabulum.  The  double  hip- 
sjilint  of  Dr.  Sayre  will  accomplish  the  necessary  extension,  while  locomo- 
tion may  be  effected  by  crutches,  or  Dr.  Case's  carriage. 

In  anchylosis  at  the  hip  with  malposition  the  thigh  is  generally  flexed 
upon  the  abdomen  and  addiicted  with  outward  rotation.  "When  destruc- 
tive osteo-arthritis  has  occurred  the  trochanter  will  be  seen  nearer  to  the 


714 


A  TEXT-BOOK   ON  SURGERY. 


iliac  crest  than  on  the  soiiml  side,  a  condition  which  does  not  exist  when 
the  anchylosis  is  simply  due  to  muscular  contractions. 

On  account  of  muscular  riu:idity  the  exact  condition  of  anchylo.sis  can 
not  usually  be  determined  witlioiit  ether  nai'cosis.  A  certain  degree  of 
mobility  is  pi-esent  as  a  rule. 

Treatmrnt. — "When  the  malposition  is  such  that  usefulness  is  im- 
paired, or  comfort  inteifered  witli,  an  effort  to  relieve  the  deformity  by 
operation  is  justifiable,  jjrovided  that  all  local  inflammatory  symptoms 
are  absent  and  that  the  general  condition  of  the  patient  is  such  that  no 
risk  is  incurred  liy  the  procedure.  Under  ordinary  conditions  the  opera- 
tion is  not  attended  with  danger. 

In  osteotomy  at  the  hip  for  the  relief  of  deformity  three  pi-ocednres 
may  be  entertained  :  Section  of  the  neck  of  the  femur,  just  above  the 
great  ti'ochanter  (Adams,  Fig.  691) ;  the  inter-trochanteric  section  of 
Sayre  (Fig.  692) ;  or  the  sub-trochanteric  operation  of  Gant  (Fig.  693). 


Fio.  691. — Adams's  line  of  sec- 
tion.    (After  I'oore.) 


Fi(i 


fifl2. — Sayre's  inter-troc-lian- 
teric  line  of  section. 


Fig.  693. — Gant's  sub-trochanteric 
line  of  section.    (After  I'oore. j 


The  objections  to  Adams's  line  of  section  is  that  often,  on  account  of  dis- 
appeai'ance  of  the  head  and  neck  of  the  bone,  it  is  impossible  ;  and,  sec- 
ondly and  chiefly,  if  disease  has  existed  at  the  joint,  this  line  of  section 
is  so  near  the  old  seat  of  osteo-arthritis  that  the  process  of  inHammation 
may  be  re-established.  In  anchylosis,  without  osteoarthritis  at  the  hip, 
it  is  to  be  preferred.  In  the  vast  majority  of  cases,  (iant's  .section — just 
at  the  lower  portion  of  the  lesser  trochanter — is  preferable.  The  ol)jects 
to  be  accomplished  are,  a  section  of  the  bone  at  this  point  at  a  light 
angle  to  the  axis  of  the  shaft,  rotation  of  the  femnr  into  its  normal  2)osi- 
tion,  and  abduction. 

8nh-frorhanteric  Odeotomy  at  tJie  Hip. — The  patient  is  placed  on  the 
sound  side,  so  that  the  femur  to  be  divided  is  well  exposed.  The  strict 
details  of  antisejisis  should  be  carried  out. 

The  upper  surface  of  the  great  trochanter  is  felt,  and  tlie  femur 
grasped  between  the  thumb  and  linger.     Upon  the  outer  portion  of  the 


SUB-TROCHANTERIC   OSTEOTOMY  AT  THE   HIP. 


715 


femur  an  incision  is  made,  commencing  about  one  incli  below  the  most 
superior  surface  of  tlie  trochanter  major,  and  extending  downward  about 
one  inch  and  a  half.  Wlien  the  bone  is  exposed,  the  wound  is  held 
open  by  retractors,  and  the  bluntest  of  Macewen's  bone-chisels  introduced 
flatwise  with  the  incision  until  the  bone  is  reached,  when  it  is  turned  so 
that  the  cutting  edge  is  across  the  axis  of  the  femur.  In  a  child  twelve 
years  old  the  lower  portion  of  the  lesser  trochanter  (the  line  of  section) 
is  about  one  and  a  half  inch  below  the  tip  of  the  great  trochanter. 

While  the  limb  is  steadied  by  an  assistant,  a  few  blows  with  the 
mallet  drives  the  chisel  through  the  outer  rim,  when  a  thinner  chisel  is 
inserted  and  the  bone  cut  from  one  half  to  three  fourths  through.  Grasp- 
ing the  thigh  near  the  knee  with  one  hand,  while  the  other  steadies  the 
part  above  the  section,  the  remaining  portion  is  readily  fractured  by 
carrying  the  thigh  toward  the  median  line.  The  wound  is  now  thor- 
oughly irrigated  and  closed  with  catgut  sutures,  leaving  a  bone-drain  out 
at  the  lower  angle.  A  sublimate  dressing 
is  applied.  The  thigh  is  rotated  slightly 
inward,  abducted  to  about  five  degrees  from 
the  axis  of  the  spine,  and  flexed  on  the  ab- 
domen so  that  the  axis  of  the  femur  Joins 
that  of  the  body  at  an  angle  of  fifteen  de- 
grees (Fig.  694).  If  in  the  position  of  de- 
formity the  thigh  is  abducted — a  condition 
which  rarely  exists — the  corrected  jiosition 
should  be  that  of  adduction  about  five  de- 
grees beyond  the  normal.  The  after-treat- 
ment is  the  same  as  for  fracture  at  this 
point,  namely,  Buck's  extension  and  Ham- 
ilton's long  splint  (page  3()4). 

In  order  to  secure  the  necessary  five  de- 
grees of  abduction,  the  padding  to  the  splint 
should  be  made  several  inches  thicker  op- 
posite the  acetabulum  than  at  the  knee,  and 
the  thigh  and  leg  should  be  elevated  upon 
pUIows  enough  to  secure  the  fifteen  degrees 
of  flexion  required.  When  consolidation 
occurs  with  the  extremity  in  this  position, 
locomotion  is  good  and  more  comfort  ex- 
perienced in  the  sitting  posture  than  when 
the  leg  is  jierfectly  straight.  At  the  end  of 
four  or  five  weeks  the  patient  may  be  al- 
lowed to  go  about  on  crutches,  and  in  eight  or  ten  weeks  to  walk  with- 
out them. 

The  result  to  be  achieved  is  osseous  reunion  at  the  point  of  fracture 
with  the  limb  in  the  improved  position.  A  false  or  new  joint  is  not 
desirable.  Esmarch's  bandage  is  not  essential  in  the  performance  of  the 
operation,  although  it  may  be  em])loyed  if  desired.  The  h;rmorrhage  is 
usually  slight,  and  a  few  catgut  ligatures  readily  control  all  bleeding 


Fio.    fi04.— ' 


jtropor  position  of  the 
extremity  alter  sub-troohanteric  os- 
teotomy.    i^Altor  I'oore.) 


716  A  TEXT-BOOK   ON   SURGERY. 

points.  Tlie  free  incision  advised  is  safer  than  to  use  the  osteotome 
through  a  narrow  wound.  Forcible  breaking  up  of  adhesions  or  fracture 
at  the  joint  is  not  permissible.  Adams's  section  is  made  through  an  in- 
cision in  the  line  advised  for  hip-joint  exsection.  Its  center  should  cor- 
respond to  a  point  just  above  the  great  trochanter.  The  chisel  should 
be  preferred  to  tlie  saw  in  making  the  section,  on  account  of  the  bone- 
dust  and  detritus  left  by  this  latter  instrument. 

Sayre's  line  is  half-way  between  Adams's  and  Gant's  lines.  The 
bone  should  be  divided  squarely  across.  The  attempt  to  form  an  arti- 
licial  balland-socket  joint  by  nudving  a  concavity  in  the  upper  fragment, 
or  rounding  off  the  upper  extremity  of  the  lower  fragment,  is  not  justi- 
iiable,  because  it  prolongs  the  operation,  and  is  a])t  to  be  followed  by 
necrosis,  with  ultimate  anchylosis.  It  is  better  to  accomplish  reunion 
at  once. 

The  deformities  of  the  shaft  of  the  femur  are  also  congenital  and 
acquired.  An  occasional  congenital  malformation  is  due  to  failure  of 
development  of  this  bone  in  its  long  axis.  The  femur  may  not  be  more 
than  six  inches  in  length,  while  the  til)ia  and  til)ula  are  normal  in  devel- 
opment. As  a  consequence  of  rickets,  the  femur  is  occasionally  curved 
outward,  causing  genu  varum,  or  bow-legs,  although,  as  will  be  seen 
later,  the  bones  of  the  leg  are  chiefly  involved  in  this  defonnity. 

Shortening,  with  or  without  angular  malposition,  is  sometimes  seen 
after  badly  united  fractures. 

For  the  relief  of  these  deformities  osteotomy  and  osteoplasis  may  be 
done  when  the  deformity  is  sufficient  to  justify  the  operation.  In  oste- 
otomy the  incision  should  be  along  the  anterior  and  external  aspect  of 
the  thigh  farthest  removed  from  the  vessels.  The  only  artery  of  im- 
portance here  is  the  descending  branch  of  the  external  circumflex.  Oste- 
oclasis is  not  permissible  unless  the  fracture  can  be  effected  by  manual 
force.  In  recent  and  badly  united  fractures,  and  in  rachitic  subjects,  this 
may  be  don(\  The  osteotome  is  preferable  to  the  osteoclast.  In  over- 
lapping fractures,  with  marked  shortening  (two  to  Ave  inches),  if  the 
union  is  not  angular,  the  deformity  may  be  corrected  and  lateral  spinal 
curvature  oV)viated  by  a  compensating  high  shoe.  If  for  {esthetic  reasons 
the  patient  insists  upon  it,  a  section  may  be  taken  from  the  sound  femur 
and  the  ends  brought  together,  as  was  done  by  Weir  in  one  instance. 
The  conditions  which  will  justify  this  procedure  are,  however,  rare. 

Occasionally  overlapping  and  badly  united  fractures  of  the  thigh  will 
be  met  with  in  which  the  callus,  which  persists,  is  so  extensive  that 
operation  at  the  seat  of  fracture  is  imi:)ossible. 

The  deformities  of  the  lower  extremity  of  the  femur  are  those  of 
hypertrophy  or  elongation  of  one  or  the  other  condyle.  The  outer  condyle 
is  only  exceptionally  enlarged.  The  consideraticm  of  these  pathological 
changes  belongs  properly  to  genu  valgum  and  rariim. 

Genu  Valgum. — When  a  normal  subject  stands  erect,  the  inclination 
of  the  femur  of  each  side  is  inward  and  toward  its  fellow,  until  the  inter- 
nal condyles  are  almost  in  contact.  In  other  words,  by  actual  measure- 
ment in  a  descent  of  eighteen  inches  from  the  head  to  the  condyloid 


GENU  VALGUM. 


717 


extremity,  a  separation  of  seven  inches  between  the  acetabula  is  reduced 


to  three  and  a  half  inches  from 
obliquity  is   slightly  increased 
in  females,  owing  to  the  broad- 
er development  of  the  pelvis. 

If  the  articular  facets  of  both 
tibiae  are  brought  firmly  and 
evenly  in  contact  with  the  con- 
dyles of  the  femur,  it  will  be 
seen  that  the  axis  of  the  tibia  is 
parallel  with  that  of  the  spine. 

Any  outward  deviation  of 
this  i)arallelism  of  the  tibia 
with  the  axis  of  the  body  con- 
stitutes the  deformity  known  as 
fienib  valgum,  knock-knee,  or 
in-knee  (Fig.  695). 

Kudck-knee  may  occur  on 
one  or  both  sides,  in  both  sexes 
and  at  all  ages.  In  exceptional 
instances  genu  valgum  may  ex- 


center  to  center  at  the  knee.     This 


Fui 


C95. — Genu  valiium — Knock-knee  or  in-knee. 
(Alter  Poorc.) 


Fig.  698. — Genu  valpum  nnd  varum  in  the  same 
patient,  in  Mount  Sinai  Hospital. 


Fio.  097.— The  sanae,  after  osteotomy  of  both 
femora.     (,The  author's  case.) 


1st  on  one  side  and  varum  on  the  other,  as  shown  in  Figs.  696  and  697. 
Knock-Jinee  is  usually  acquired ;  occasionally  corir/rnital.  It  is  most 
frequently  seen  in  children  and  young  adults  suffering  from  an  acquired 


718  A  TEXT-BOOK  ON  SURGERY. 

or  hereditary  dyscrasia.  As  to  tlie  causes,  we  must  look  chiefly  to 
changes  in  the  bones  at  or  near  tlie  knee-joint.  Any  interference  with  the 
normal  processes  of  nutrition  and  development  in  the  bones  will  account 
for  most  cases  of  knock-knee,  and  the  chief  pathological  condition  is  either 
that  of  rachitis,  or  one  so  closely  allied  to  it  that  a  distinction  is  difficult. 

The  most  classical  osseous  lesion  in  genu  valgum  is  the  enlargement 
of  the  internal  condyle  as  compared  to  the  external,  and  the  resulting 
increase  of  the  normal  obliquity  of  the  tibio-femoral  articulation.  This 
increased  obliquity  may  be  due  to  hy])ertrophy  of  the  inner  condyle  ;  or 
to  hypertrophy  of  the  inner  half  ()f  the  ujjper  tibial  epipiiysis ;  to  atrophy 
of  the  outer  condyle,  or  atrophy  of  the  outer  half  of  the  upper  tibial 
epiphysis;  to  a  combination  of  two  or  more  of  tliese  conditions;  to  a 
curve  of  the  femur  (convexity  inward)  from  rickets,  and  to  a  like  curve 
of  the  tibia  and  fibula. 

There  is  no  anatomical  reason  why  the  intei'ual  condyle  should  enjoy 
a  better  nutrition  ;uid  gi'eater  development  than  the  outer.  There  is, 
however,  a  very  good  mechanical  explanation  in  this,  that  by  reason  of 
the  marked  ol)liquity  of  the  femoral  axis  and  the  perpendicular  directi(m 
of  the  tibial  shaft  when  the  subject  is  standing  erect,  tlie  line  of  gravity 
brings  the  greater  weight  upon  the  outer  facet  of  the  tibia  and  the  cor- 
responding condyle  of  the  femur.  The  distribution  of  this  pressure 
equally  over  the  entire  articular  surface  belongs  to  the  muscles  control- 
ling this  joint ;  but  owing  to  the  excessive  number  and  greater  power  in 
the  adductor  as  compared  to  the  abductor  group,  the  internal  obliquity  is 
maintained  and  the  pressure  upon  the  outer  articular  surfaces  increased. 
In  the  rachitic  condition  the  bones  are  softened,  and  become  distorted 
under  pressure,  and  as  a  result  of  muscular  action,  while  such  deformi- 
ties are  resisted  by  the  normal  bones. 

Knock-kuee  from  incurvation  of  the  shaft  of  the  os  femoris  alone  is 
exceedingly  rare.  When  not  due  to  abnormal  changes  in  the  condyles, 
the  cause  of  this  defoi'mity  will  usually  be  found  in  rachitic  disease  of 
the  tibia  and  fibula,  in  which  these  bones  are  bent  inward  at  the  middle 
or  lower  third.  The  principal  changes  in  the  soft  parts  are  elongation  of 
the  internal  lateral  ligaments,  and  a  contractured  condition  of  the  ))iceps 
and  popliteus  muscles. 

Symptoms. — The  symptoms  of  knock-knee  vary  in  different  stages  of 
the  deformity.  The  approximation  of  the  knees  is  a  less  noticeable 
feature  than  the  divergence  of  the  tibiae.  With  the  lower  extremities 
fully  extended,  and  the  knees  in  contact,  it  will  be  noticed  that  the  inner 
malleoli  are  separated  from  a  few  inclies  to  a  foot  or  more.  When  the 
lesion  is  due  to  changes  in  the  inner  condyle  of  the  femur,  it  will  be 
observed  that,  if  the  leg  is  flexed  upon  the  thigh  at  an  angle  of  90°,  the 
deformity  is  less  apparent ;  and  if  complete  flexion  is  made  in  mild  cases 
of  in-knee,  it  will  disappear  altogether  ;  i.  e.,  the  tibia  in  extreme  flexion 
will  be  parallel  with  the  femur.  The  patella  is  displaced  outward,  and 
locomotion  is  more  or  less  impaired.  Pain  is  often  present,  from  the 
unnatural  strain  upon  the  tissues,  and  fatigue  with  the  slightest  exertion 
is  often  noticed. 


GENU  VALGUM. 


719 


The  diagnosis  rests  upon  the  recognition  of  the  symptoms  just 
detailed,  and  the  proiinosis  is  generally  favoiable  when  judicious 
and  persistent  treatment  is  instituted.  Constitutional  remedies  and 
mechanical  appliances  are  indicated  early  in  the  disease,  and  opei-a- 
tive  interference  is  justifiable  when  mechanical  treatment  can  not  effect 
a  cure. 

The  first  indication  is  met  in  out-of-door  life,  good  food,  diversion, 
tonics,  cod-liver  oil,  and  the  hyi)oph(jsphites  of  lime  and  soda. 

The  mechanical  treatment  should  be  insisted  upon  in  all  cases  of  chil- 
dren in  which  the  deformity  is  not  exaggerated,  and  should  be  persisted 
in  for  several  years,  if  necessary.  Any  mechan- 
ism which  is  applicable  in  this  deformity  must 
afford  a  fixed  point,  opposite  to  and  on  the  ex- 
ternal aspect  of  the  region  of  the  knee-joint,  from 
which  constant  traction  may  be  made.  The  appa- 
ratus of  Prof.  Sayre  (Fig.  698)  will  be  found  of 
great  use  in  meeting  the  chief  indications.  It 
consists  of  a  pelvic  belt  of  steel,  padded  so  as 
not  to  excoriate,  and  a  bar  of  steel  hinged  at  the 
knee,  and  passing  down  from  the  belt  to  the  sole 
of  the  shoe,  where  it  is  fastened,  as  in  the  long 
hip-splint  already  described. 

Opposite  each  knee,  and  just  above  and  be- 
low the  joints — in  order  to  distribute  the  press- 
ure over  a  wider  area,  and  thus  prevent  chafing  or 
excoriations — are  padded  belts  or  bands  which 
surround  the  limb ;  these  are  attached  to  the 
side-bars,  and  may  be  tightened  at  will  in  exer- 
cising the  required  traction  to  overcome  the  deformity.  Elastic  tension 
by  means  of  rubber  bands  or  webbing  may  also  be  utilized  in  this  man- 
ner. The  hinges  at  the  knees  allow  the  patient  to  bend  these  joints  in 
walking  and  when  it  is  desired  to  assume  the  sitting  posture.  The 
instrument  should  be  worn  during  the  waking  hours,  and  at  night  it 
will  be  advisable  to  make  extension  from  both  legs  by  Buck's  method. 
The  cost  of  this  apparatus  places  it  beyond  the  reach  of  many  patients, 
and  in  this  class  of  cases  renders  early  operative  interference  more  jus- 
tifiable. 

Osteotomy  of  the  femur  for  the  correction  of  chronic  cases  of  genu 
valgum  is  an  operation  practically  free  from  danger,  and  yields  excel- 
lent results.  The  section  should  be  made  above  the  joint,  and  away 
from  it  a  sufficient  distance  to  avoid  all  danger  of  entering  the  aiticula- 
tion  or  injuring  the  epiphysis.  Linear  section  should  be  preferred,  since 
it  is  simpler  than  cuneiform  osteotomy,  and  is  ecpud  to  the  correction  of 
all  cases  excepting  those  in  v.hich  there  is  extreme  angularity  at  the  seat 
of  deformity.  Such  conditions  rarely,  if  ever,  occur  in  the  femur.  The 
older  operations  of  Ogston,  Reeves,  Chiene,  and  IMacewen,  which  in- 
volved the  joint,  are  practically  discarded.  They  are  objectionable  in 
this,  that  they  invade  the  joint  and  endanger  the  functions  of  this  im- 


Fio.  608. — Sayre's  apparatus  for 
the  correction  of  kuock-kiiee. 
(After  Sayre.) 


720 


A  TEXT-BOOK   ON  SURGERY. 


portant  articulation.*  Transverse  section  above  the  epiphyseal  line,  from 
the  outside  (MacCormac)  or  inner  side  (Macewen),  should  be  prefei-red 
(Fig.  703). 

Jfaceicen^s  Operation. — In  this  procedure  it  is  intended  to  divide  the 
femur  at  a  right  angle  to  its  axis  through  two  thirds  to  three  fourths  of 
its  thickness,  at  a  point  well  above  the  level  of  the 
lower  epiphysis.  In  a  child  ten  years  old  the  line 
of  section  should  be  one  and  three  quarter  inch 
above  the  most  dependent  portion  of  the  articular 
surface  of  the  internal  condyle,  and  in  an  adult  two 
and  a  half  inches. 

Strict  antiseptic  precautions  should  be  taken. 
If  Esmarch's  bandage  is  a])]ilied  as  high  as  the  mid- 
dle of  the  thigh,  the  wound  will  be  kept  dry  and 
the  operation  greatly  facilitated.  I-i'lex  the  leg  on 
the  thigh  and  rotate  the  thigh  outward  so  as  to 
bring  the  inner  aspect  of  the  joint  upward.  Make 
an  incision  one  inch  long,  following  the  dii-ection  of 
the  internal  condyloid  lidge.  The  center  of  this  in- 
cision should  be  opposite  the  point  of  section  above 
given.  The  internal  sphenous  vein  and  the  anas- 
tomotica  magna  artery  should  be  avoided,  and  the  tubercle  for  the 
insertion  of  the  tendon  of  the  adductor  magnus  felt.  As  soon  as  the 
bone  is  reached  the  chisel  is  carried  down  to  it,  parallel  with  the  incision, 
and  immediately  turned  with  its  cutting  edge  at  a  right  angle  to  the  axis 
of  the  femur.  The  inner  and  anterior  shell  of  compact  tissue  should  be 
first  divided,  and  when  the  posterior  portion  is  cut  through  the  osteotome 
should  be  directed  to  the  front  so  that  when  struck  with  the  mallet  it  wiU 
be  carried  away  from  the  vessels.  As  soon  as  the  bone  is  cut  through  two 
thirds  of  its  thickness,  the  remaining  piece  may  be  fractured  by  grasping 
the  limb  above  and  below  the  section,  and  using  the  other  hand  for  a 
fulcrum  and  the  leg  as  a  lever,  which  is  caiTied  outward.  As  soon  as 
the  bone  snaps,  the  leg  is  handed  to  an  assistant,  who  is  directed  to  steady 


Fio.  703. — (J,   MacCormnc's 
line.    A,  Macewen's  line. 


*  Figs.  699-702.    (After  Poore.) 


Fig.  699.— Ogston.  Fig.  700.— Reeves.  Fig.  701.— Chiene.  Fio.  702.— Maeewen. 


GENU  VARUM.  721 

it  by  making  strong  extension.  The  wound  should  now  be  inigated  with 
1-3500  sublimate,  a  si)onge  ai)plied  as  a  compress,  held  in  place  by  a  roller, 
and  the  tourniquet  removed.  In  live  minutes,  if  no  bleeding  of  impor- 
tance occurs,  the  sponge  may  be  removed  and  a  di-essing  of  iodoform 
and  sublimate  gauze  ajiplied.  The  limb  should  be  brought  into  the 
straight  position  by  extension,  and  steadily  held  until  a  plaster-of-Paris 
bandage  is  put  on  and  hardened.  This  dressing  is  allowed  to  remain  for 
four  or  five  weeks,  as  in  simple  fracture,  when  it  is  removed,  and  passive 
motion  made  at  the  joint.  It  is  reapplied  for  a  week  longer,  and  then,  as 
a  rule,  may  be  discontinued.  MacCormac's  procedure  is  practically  the 
same  as  the  above,  with  the  exception  that  the  section  is  made  fi'om  the 
outer  side  of  the  femur.  Of  these  two  operations  the  incision  from  the 
outer  side  (MacCoimac's)  is  preferable,  for  the  reason  that  there  are  no 
vessels  in  the  way.  On  the  inner  side  the  long  saphenous  vein  and  the 
anastomotica  magna  artery  are  endangered.  Moreover,  it  does  not  matter 
from  which  side  the  bone  proper  is  divided,  as  far  as  the  correction  of  the 
defoi-mity  is  concerned.  When  the  tibia  and  fibula  are  involved  in  the 
deformity,  section  of  these  bones  may  be  required  at  the  same  or  a  sub- 
sequent operation. 

Oeiiu  Varum. — In  bow-leg,  or  outward  curvature  of  the  lower  ex- 
tremity, one  or  both  members  may  be  involved.     The  bones  of  the  leg 
are  usually  alone  involved,  although 
in  some  instances  the  femur  may  take 
part  in  the  deformity  (Fig.  704). 

The  principal  cause  of  bow-legs  is 
rickets,  the  softened  bones  yielding  to 
the  weight  of  the  body  or  to  muscu- 
lar contractions.  Genu  varum  is  usu- 
ally met  with  in  childhood,  but  may 
occur  in  adults  who  are  rachitic.  In 
treatment,  the  indications  are  the  same 
as  for  knock-knee.  The  adjustment 
of  any  mechanical  apparatus  is,  how- 
ever, more  difficult.  Splints  should 
be  adjusted  to  prevent  further  deform- 
ity, or  the  patient  should  be  prevent- 

■»  ,.        .  ,  •    1  ,       e      •{  ''0.  T04. — Genu  varum,  or  bow-legs. 

etl   trom  bringing  the  weight  of  the  (After  Pooie.) 

body  upon  the   diseased  bones.     In 

the  mean  while  every  effort  should  be  made  to  correct  the  dyscrasia. 
As  long  as  the  bones  remain  in  the  softened  condition  of  rickets,  oper- 
ative interference  is  not  indicated.  Osteotomy  of  the  tibia  and  fibula 
at  the  point  where  the  outward  curve  is  most  pronounced  will,  in  the 
majority  of  instances,  correct  the  deformity.  In  extreme  cases  it  may 
be  necessary  to  make  sections  at  two  or  more  points.  If  the  feuuir 
is  involved  it  should  also  be  divided,  although  this  complication  will 
rarely  be  met  with.  The  details  of  the  operation  and  the  after-treatment 
are  practically  the  same  as  for  genu  valgum. 

Osteoclasis  should  be  substituted  for  osteotomy  only  in  those  cases 

46 


722  A  TEXT-BOOK   ON  SURGERY. 

in  which  the  fracture  may  be  accomplished  with  little  force  and  with 
the  hands  of  the  operator.  It  is  objectionable  when  performed  with  the 
osteoclast,  for  the  reason  that  the  soft  tissues  are  bruised  to  an  extent 
which  does  not  occur  in  osteotomy.  Moreover,  the  line  of  fracture  can 
not  be  directed  with  the  same  accuracy  as  in  cutting  with  the  chisel. 
The  necessity  for  the  exclusion  of  air  no  longer  exists  in  the  use  of  std)- 
liniate  irrigation  and  the  antiseptic  dressing. 

Ancliylosis  at  the  Knee,  with  Malposition.— For  the  correctinn  of 
tliis  deformity  osteotomy  is  at  times  performed.  "When  the  degree  of 
malposition  is  extreme,  it  may  become  necessary  to  divide  the  femur  at 
a  point  from  three  to  four  inches  above  the  most  dependent  portion  of 
the  articular  surface  of  this  bone.  If  after  this  section  the  limb  can  not 
be  brought  out  straight,  division  of  the  tibia  just  below  the  tuberosity 
may  be  done.  Exsection  of  the  knee  is,  however,  a  preferable  operation; 
and,  since  in  modern  practice  the  danger  of  this  precedure  is  so  greatly 
diminished,  it  is  believed  that  the  operation  through  the  articulation 
will  supersede  section  of  the  bone  in  continuity. 

Talipes. — Club-foot  is  a  deformity  in  which  there  exists  cither  an 
abnormal  relation  between  the  bones  of  the  foot  to  each  other,  or  to  the 
tibia  and  fibula.  There  are  six  simple  and  several  compound  forms  of 
talipes.  The  simjile  varieties  are  talipes  equinus,  calcaneus,  varus, 
valgus,  cavus,  and  ^plaiius.  Among  the  compound  forms  are  those  of 
equino-valgus,  equino-varus,  calcaneo-valgus,  calcaneo-varus,  etc. 

In  talipes  equinus  the  heel  is  drawn  up,  and  the  weight  of  the  body 
falls  upon  the  plantar  aspect  of  the  metatarsus,  the  toes  and  phalanges ; 
the  gastrocnemius  and  soleus  are  shortened,  the  tendo  Achillis  tense, 
and  in  extreme  cases  the  heel  can  not  be  brought  down  to  the  ground. 


Fig.  705. 


Fio.  roe. 


CongCDital  talipes  equinuR.     (Aft*r  Cliurchill.> 


Callosities  are  formed  upon  the  sole  of  the  foot  along  the  metatarso- 
phalangeal line.  When  paralysis  of  the  anterior  muscles  of  the  leg  has 
taken  place,  the  toes  are  turned  under,  as  in  Fig.  708.     In  this  conditicm 


TALIPES. 


r23 


there  are  atrophy  and  complete  loss  of  power  in  the  tibialis  anticus,  pero- 
neus  tertius,  extensor  longus  digitorum,  and  extensor  pollicis  muscles. 
Simple  talipes  equinns  is  not  of  very  frequent  occurrence,  since  it  is 


Fig.  VOr. 
Acquired  talipes  equinus.      In  Fig 


Fig.  TOS. 

TOS  there  has  ocpurrod  complett  paralysis  of  the  extensor  muscles. 
(Alter  Churchill.) 


almost  always  complicated  wdth  inward  rotation  of  the  tarsus,  or  talipes 
equino-varus. 

Treatment. — "When  complete  paralysis  has  not  occurred,  and  if  taken 
early,  talipes  equinus,  whether  congenital  or  acquired,  may  be  cured,  or 
marked  deformity  prevented,  by  the  institution  of 
proper  treatment.  Section  of  the  tendo  Achillis  is 
rarely  necessary  when  the  case  has  not  been  neglect- 
ed. The  propriety  of  tenotomy  can  be  determined  by 
the  degree  of  resistance  met  with  in  the  effort  to  bring 
the  sole  of  the  foot  to  a  right  angle  with  the  axis  of 
the  leg.  If  this  can  not  be  accomplished,  or  if,  when 
the  tarsus  is  firmly  Hexed  on  the  leg,  pressure  Tipon 
the  sural  muscles  produces  a  painful  and  marked 
spasm  (Sayre),  tenotomy  is  indicated,  especially  in 
those  patients  who  can  not  afford  the  long-continued 
expense  of  mechanical  treatment,  and  who  of  neces- 
sity can  not  remain  long  in  the  hands  of  an  experi- 
enced surgeon.  In  simple  equinus  the  indications  are 
to  overcome  the  muscular  contraction  by  artiticial  ap- 
pliances, and  to  restore  the  normal  tonicity  and  power  to  tlie  anterior 
tibial  group  of  miiscle. 

AVhen  a  child  is  born  with  taliiies  equinus  (and  all  forms  of  congenital 
club-foot  sliould  be  treated  from  birth),  deformity  of  the  bones  of  the 
foot,  and  the  too  great  stretching  or  elongation  of  the  anterior  muscles, 
may  be  prevented  by  the  following  sim])le  means:  Cut  a  ])iece  of  light 
board  as  wide  as  the  sole,  and  a  little  longer  than  the  foot,  and  cover  it 


Fig.  709.— Bone-i  of  the 
loot  of  an  adult  with 
talipes  equinus.  (Aft- 
er Chance  and  Noble 
Smith.) 


724 


A  TEXT-BOOK   ON   SURGERY, 


witli  adhesive  plaster  in  siu-h  a  way  that  the  sticking  surface  is  next  to 
the  skin.  This  is  laid  along  the  sole  of  the  foot,  to  which  it  is  fastened 
by  adhesive  stri])s,  and  a  light  bandage,  leaving  the  end  of  tlie  board  to 
project  a  little  beyond  the  toes.  From  the  end  of  tlie  board  traction 
may  be  made  by  a  strip  of  plaster  carried  njiward  and  fastened  along 
tlie  front  of  the  leg  near  the  knee,  sufficient  tension  Ix-ing  exercised  to 
draw  the  foot  into  its  natural  position.  Or,  if  deemed  necessary,  arti- 
ficial muscles  (rubber  tubing)  may  be  attached  from  the  tip  of  the  board 
to  insertions  fastened  near  the  knee  on  the  antero-lateral  aspects  of  the 
leg.  Tlie  apparatus  must  be  carefully  readjusted  whenever  it  becomes 
loose  or  causes  pain. 

AVhen  the  patient  is  able  to  walk,  simple  cases  of  e(piinus  may  be 
corrected  by  weaiing  a  stiff,  solid,  and  well-constructed  laced  shoe,  which 
will  hold  the  instep  well  down  and  keep  the  sole  of  the  foot  in  close 
contact  with  the  sole  of  the  shoe.  The  weight  of  the  body,  falling  upon 
the  anterior  portion  of  the  foot,  will  aid  in  carrying  the  heel  to  the 
ground  with  each  step. 

In  moi-e  obstinate  cases  the  Sayre  shoe  (Fig.  710)  more  nearly  meets 
the  mechanical  indications  than  any  other  apparatus.     When  there  is 

no  inversion  of  the  foot  (varus),  the  lateral  rub- 
ber muscle  J  G  is  unnecessary.  In  ordering  this 
shoe  it  is  advisable  to  send  to  the  instrnment- 
maker  the  shoe  at  tlie  time  worn  by  the  pa- 
tient, and  with  this  the  distance  from  the  sole 
of  the  heel  to  the  upper  articular  margin  of  the 
tibia,  as  well  as  the  circumference  of  the  leg  at 
this  point.  To  this  may  be  added  the  measure- 
ments around  the  foot,  at  the  bases  of  the  toes, 
and  around  the  malleoli.  In  all  cases  of  talipes 
in  walking  children  and  adults,  it  is  important 
that  all  excoriations  be  healed  before  any  a])i)li- 
auce  is  adjusted. 

The  idea  must  not,  however,  be  entertained 
that  the  simple  api)lication  of  the  shoe,  or  any 
mechanical  appliance,  will  correct  the  deformity. 
The  after-treatment  is  a  most  important  feature  in  these  cases.  Electrici- 
ty and  massage  are  important  adjuvants.  The  weaker  galvanic  current 
should  be  prefeiTed,  the  positive  pole  being  placed  along  the  track  of 
the  nerve  which  supplies  the  affected  muscles,  while  the  negative  sponge 
is  carried  over  the  bellies  of  these  muscles.  The  application  should  be 
made  about  twice  each  week,  whUe  massage  should  be  employed  twice 
daily. 

In  those  cases  where  tenotomy  is  deemed  advisable,  the  operation  is 
lierformed  as  follows :  The  patient  being  placed  under  the  influence  of 
an  anaesthetic,  the  tarsus  is  Hexed  forcibly  upon  the  leg,  in  order  to  place 
the  tendo  Achillis  and  plantar  fascia  upon  the  stretch  ;  a  slight  puncture 
of  the  skin  is  then  made,  a  little  anterior  to  the  tendon,  and  on  the  inner 
side  of  the  leg,  slightly  above  the  malleolus  ;  this  opening  is  now  carried 


KlB 


•">ir,:.  .  ;,_ 


710. — Sayre's  rlul'-tbot  shoo. 
(A:ter  Suyre.) 


TALIPES  CALCANEUS. 


725 


to  the  edge  of  the  tendon  by  traction  ui)()n  the  integument,  and  the 
tenotome  introduced,  with  its  flat  surface  toward  the  tendon.  The  ten- 
sion upon  the  tissues  is  now  relaxed,  and  tlie  edge  of  the  knife  turned 
toward  the  parts  to  be  divided ;  the  tarsus  is  flexed  strongly  upon  the 
leg,  and  the  tendon  again  made  tense,  when  the  knife  is  pressed  forward 
and  outward  through  the  tendon,  which  separates  with  a  very  audible 
snap.  The  thumb  of  the  operator  being  placed  over  the  tendon  exter- 
nally, acts  as  a  guide  and  support,  preventing  the  blade  from  passing 
through  the  integument  and  causing  an  open  wound,  an  accident  which 
should  be  carefully  avoided.  As  soon  as  the  division  of  the  tissues  is 
effected,  the  blade  of  the  knife  should  be  withdrawn,  flatwise,  and  the 
thumb  of  the  operator  slipped  over  the  slight  puncture,  which  is  at  once 
covered  with  one  or  two  strips  of  adhesive  plaster  ;  the  plantar  fascia  can 
be  divided  in  a  similar  manner,  if  desirable,  the  whole  foot  being  then 
enveloped  in  cotton,  and  a  snug  roller  bandage  applied.  The  foot  is  now 
secured,  by  mechanical  appliances,  at  a  right  angle  to  the  leg,  as  hereto- 
fore described.  Division  of  the  extensor  tendons  of  the  toes  is  not  often 
required.  The  best  point  of  section  is  just  over  the  metatarso-phalangeal 
articulation. 

Talipes  Calcaneus. — In  this  rare  form  of  club-foot  the  toes  are  drawTi 
upward  and  the  tarsus  flexed  upon  the  tibia ;  impairment  of  function 

exists  in  one  or  more  of  the  sural 
muscles  ;  the  tibialis  anticus,  pero- 
neus  tertins,  extensor  longus  digito- 
rum,  and  pollicis  are  shortened.  This 
deformity  may  be  either  congenital 


Fill.  711. — CotiiTonital  talipes  calcaneus. 
(AltLT  Churcliill.) 


Fig.  T1'2. — Acquired  talipes  calcaneus. 
(Alter  fhureliill.) 


or  acquired  (Figs.  71],  712).  It  is  usually  met  with  in  children,  or  may 
occur  at  any  period  of  life,  from  rupture  of  the  tendo  Achillis,  or  paral- 
ysis of  the  muscles  of  the  calf  of  the  leg,  ununited  fracture  of  the  os 
calcis,  etc.  In  this  condition  the  mechanical  and  suigical  appliances  and 
treatment  are  exactly  opposite  to  those  of  the  preceding  variety.  An 
nnunited  section  of  the  tendo  Achillis  should  be  corrected  by  cutting 
down  upon  this  tendon  at  the  seat  of  the  division,  freshening  the  divided 


726 


A  TEXT-BOOK  ON  SURGERY. 


ends,  and  sewing  them  together  with  .silk  .sutures.  Mild  cases  of  calca- 
neus m:iy  be  relieved  by  the  wearing  of  a  well-lit  ting,  laced  shoe,  the 
weight  of  the  body  aiding  in  correcting  the  deformity.  AVhen  the  toes 
can  not  be  brought  down  without  the  aid  of  additional  pressure,  the 
ai)paratus  in  construction  similar  to  the  one  recommended  for  flat-foot 
can  be  api)lied.  Tlie  object  to  be  obtained  is  to  elevate  the  lieel  and 
depress  the  toes  by  mechanical  means.  For  this  purjiose,  the  shoe  as 
devised  by  Dr.  Sayre  (Fig.  713)  is  admirably  adapted.  This  is  a  strong, 
laced  shoe,  with  steel  rods  running  up  on  either  side  of  the  leg  to  a 
collar  below  the  knee,  the  rods  being  hinged  at  the  ankle  to  allow  of 
free  motion  at  this  joint ;  from  the  heel  of  the  shoe  a  small  steel  spur  is 
seen,  to  which  is  secured  a  strong  piece  of  elastic,  passing  uj)  to  the 
collar  around  the  leg.  This  rubber  artificial  muscle,  taking  the  place 
of  the  gastrocnemius  and  soleus  muscles,  if  made  of  sufficient  tension, 
will  elevate  the  heel  and  restore  the  foot 
to  its  normal  position.  There  are,  how- 
ever, various  instruments  for  the  correc- 
tion of  this  deformity,  the  surgeon  modi- 
fying the  shoe  as  may  be  required  to  suit 
each  case.  In  addition  to  the  mechani- 
cal appliances,  the  after-treatment,  by 
electricity,  massage,  etc.,  should  be  car- 


Fia.  713. — Sayrf's  shoe  t'lr  t.ilipcs  calcaneus. 
(After  Say  re.  J 

ried  out  as  in  otlier  forms  of  club-foot 
where  atrophy  of  the  muscles  and  loss  of 
power  exist. 

Talipes  Varus  and  Eqnino-Varus. — 
These  deformities  consist  of  an  inward 
rotation  of  the  foot,  and  are  the  most 
common  forms  of  talipes  (Figs.  714-717). 
The  majority  of  cases  are  those  in  which 
spastic  contraction  of  the  sural  muscles 
also  occurs  (equino-varus).  Talipes  varus  and  equino-varus  are  more 
often  congenital,  but  are  frequently  acquired,  one  or  both  feet  being  in- 
volved.    The  degree  of  deformity  varies  from  slight  inversion  of  the  foot 


Fio.  714. — Talipes  cqnino-vanis  in  an  adults 
(After  Churchill.; 


talipp:s  varus  and  EQUINO-VARUS. 


7-27 


to  the  most  exaggerated  form  in  which  the  sole  looks  upward,  while  in 
the  act  of  walking  the  dorsum  rests  upon  the  ground. 

The  changes  which  the  structures  of  the  foot  undergo  are  shortening 
of  the  plantar  fascia  and  the  internal  lateral  ligaments,  together  with 


Fiij.  710. 
Three  gnules  of  talipes  varus.     (Atler  Cliurehill.) 


Fio.  717 


a  contractured  condition  of  the  tibialis  anticus  and.  posticus  muscles. 
This  defoi-mity,  therefoi-e,  places  those  muscles  and  ligaments  upon  the 
stretch  which  are  situated  Tipon  the  outer  aspect  of  the  leg,  and  re- 
sults from  complete  or  partial  paralysis  of  the  peronei  muscles.  The 
displacement  of  the  bones  of  the  tarsus  will  correspond  to  the  extent 
of  the  deformity ;  the  astragalus  being  tilted  downward,  the  scaphoid 
is  displaced  inward  and  downward  by  the  action  of  the  tibialis  posti- 
cus, the  tubercle  on  this  bone  becoming  very  prominent ;  there  is  in 
addition  marked  rotation  at  the  astragalo-scaphoid  and  oalcaneo-cuboid 
junctions,  the  displacement  being  especially  marked  in  this  last-named 
articulation. 

When  the  deformity  exists  at  birth,  if  not  corrected  early,  the  bones 
will  become  ossified,  and  the  deformity  permanent.  In  these  cases  tar- 
sotomy and  exsection  are  the  only  means  of  bringing  the  foot  into  its 
normal  positicm. 

The  ti'eatment  of  talipes  equino-varus  in  the  infant  consists  in  the 
application  of  small  rubber  bands  or  ])ieces  of  tubing,  which  will  make 
constant  and  gradual  traction  in  the  line  of  the  weakened  or  jiaralyzed 
muscles.     This  [BarwelV s)  method  is  as  follows  : 

Cut  a  piece  of  strong  adhesive  plaster  into  the  shape  of  a  fan,  whicli 
is  split  into  four  or  five  strips  converging  toward  the  apex  of  the  fan 
(Fig.  718).  "  The  apex  of  the  triangle  is  passed  through  a  wire  loop  with 
a  ring  in  the  top  (Pigs.  718,  719),  brought  back  ujion  itself,  and  secured 
by  sewing.  The  plaster  is  firmly  secured  to  the  foot  in  such  a  manner 
that  the  wire  eye  shall  be  at  a  point  where  we  wish  to  imitate  the  inser- 
tion of  the  muscle,  and  that  it  shall  draw  evenly  on  all  ]iarts  of  the  foot 
when  the  traction  is  applied.  Secure  this  by  other  adhesive  straps  and 
a  smoothly  adjusted  roller. 


728 


A  TEXT-BOOK  ON  SURGERY. 


"The  artificial  origin  of  the  muscle  is  made  as  follows  :  Cut  a  strip  of 
tin  or  zinc  plate,  in  length  about  two  thirds  that  of  the  tibia,  and  in 
width  one  quarter  the  circumference  of  the  limb  (Fig.  720).  This  is 
shaped  to  tit  the  limb  as  well  as  can  be  done  conveniently.     About  an 


Fid.  T19.— (After  Sayre.) 


Fio.  718.— (.-Vfter  Sayre.) 


Fig.  T20.— (After  Sayre.) 


inch  from  the  upper  end  fasten  an  eye  of  wire.  Care  should  be  taken 
not  to  have  this  too  large,  as  it  would  not  confine  the  rubber  to  a  fixed 
point.  The  tin  is  secured  upon  the  limb  in  the  following  manner :  From 
stout  (mole-skin)  plaster  cut  two  strips  long  enough  to  encircle  the  liml), 
and  in  the  middle  of  each  make  two  slits  just  large  enough  to  admit  the 


Fio.  721.— (From  Bam-ell.) 


Fio.  722.— (From  Barwoll.) 


tin,  which  will  prevent  any  lateral  motion ;  then  cut  a  strip  of  plaster, 
rather  more  than  twice  as  long  as  the  tin,  and  a  little  wider :  apply  this 
smoothly  to  the  side  of  the  leg  on  which  the  traction  is  to  be  made, 
beginning  as  high  up  as  the  tuberosity  of  the  tibia.    Lay  upon  it  the  tin, 


TALIPES   VARUS  AND   EQUINO-VARUS.  729 

placing  the  upper  end  level  with  that  of  the  plaster  (Fig.  721).  Secure 
this  by  passing  the  two  strips  above  mentioned  around  the  limb  (Fig. 
722),  then  turn  the  vertical  strip  of  plaster  upward  upon  the  tin.  A  slit 
should  be  made  in  the  plaster  where  it  passes  over  the  eye,  in  order  that 
the  latter  may  protrude.  The  I'oller  should  then  be  continued 
smoothly  up  the  limb  to  the  top  of  the  tin.  The  plaster  is  again  ^ 
reversed  and  brought  down  over  the  bandage,  another  slit  being  Q 

made  for  the  eye,  and  the  whole  secured  by  a  few  turns  of  the      fig.  723. 
roller.     A  small  chain,  a  few  inches  in  length,  containing  a 
dozen  or  twenty  links  for  gi'aduating  the  adjustment,  is  then 
secured  to  the  eye  in  the  tin. 

"Into either  end  of  a  piece  of  ordinary  India-rubber  tubing, 
about  one  quarter  of  an  inch  in  diameter  and  two  to  six  inches 
in  length,  hooks  of  the  pattern  shown  in  Fig.  723  are  fastened 
by  a  wire  or  other  strong  ligature.  One  hook  (Fig.  722)  is  fast- 
ened to  the  wire  loop  on  the  plaster  on  the  foot,  and  the  other  "^ 
to  the  chain  above  mentioned,  the  various  links  making  the  fig.  T24. 
necessary  changes  in  the  adjustment. 

"The  dressing,  when  complete,  is  shown  in  Fig.  722."     (Sayre.) 
A  roller  should  now  be  carefully  and  smoothly  applied  over  the  plas- 
ter and  between  the  leg  and  the  artificial  muscles. 

When  the  muscles  can  not  be  obtained,  and  in  mild  cases,  in  which 
the  foot  may  be  brought  readily  into  position,  a  correction  may  be  effected 
by  means  of  one  or  more  strips  of  adhesive  plaster  as  follows  :  One  end  of 
the  strip  is  laid  upon  the  dorsum  of  the  foot,  near  the  bases  of  the  third 
and  fourth  toes,  whence  it  is  carried  in  a  slightly  spiral  direction  to  the 
inner  border  of  the  sole,  and  across  the  sole  to  the  outer  margin  of  the 
foot.  As  the  foot  is  now  brought  into  a  normal  position  by  the  hand  of 
the  operator,  the  strip  of  plaster  is  laid  along  the  outer  and  anterior 
aspect  of  the  leg  and  thigh,  and  firmly  secured  by  encii-cling  strips  of  the 
same  material.     A  bandage  over  all  will  hold  the  dressing  in  position. 

When  the  patient  is  able  to  walk,  the  club-foot  shoe 
(Fig.  710)  will  give  the  greatest  satisfaction.     The  rub- 
ber muscles  should  be  applied  and  regulated  in  such  a 
way  that  they  will  imitate  as  nearly  as  possible  the  nor- 
mal action  of  the  muscles  they  are  intended  to  assist. 
A  less  expensive  instrument,  one   which   yields  good 
results  in  the  mUder  forms  of  talipes  eipiino-varus,  and 
which  may  be  readily  made  by  any  ordinary  worker  in 
iron,  is  shown  in  Fig.  725.     It  consists  of  a  sole-jnece  of 
sheet-iron,  which  is  riveted  to  a  heel-piece  of  the  same 
material,  and  is  roomy  enough  to  hold  the  heel  of  the 
patient  without  chafing.     It  should  be  nicely  padded, 
Fio.  725.— Iron  shoe     to  prevent  the  danger  of  excoriations.     To   tliis  heel- 
ami  equmo-va'r'ii!     piece  is  attached,  by  a  hinge-joint  with  limited  forward 
and  backward  motion,  an  iron  bar  which  extends  to  the 
padded  iron  collar  around  the  leg,  near  the  knee.      The  foot  of  the  pa- 
tient is  secured  to  the  sole-piece  by  adhesive  plaster,  with  the  aid  of  the 


730 


A  TEXT-BOOK   ON   SURGERY. 


instep-strap  shown  in  Fig.  720,  and  a  flannel  roller  carried  over  all.  As 
the  perpendicular  bar  is  now  carried  parallel  with  the  leg,  and  held  in 
this  position  by  buckling 
the  collar  around  the  leg  at 
tlie  knee,  the  foot  is  turned 
outward  and  held  in  its 
normal  position.  An  ordi- 
nary lacing-shoe  should  be 
■worn  over  the  brace. 


Outer  view. 


Inner  view. 


Fio.  727. — Reeves's  universal  shoe,  as  it  is  being  applied  in 
the  treatment  of  talipes  equino-varus.     (.\fter  Keeves.) 


Fio.  726. — Iron  shoe  tor  talipes  vanis  and 
equino-varus  in  position.  Tlie  adJie- 
aive  strips  and  bandage  have  been 
omitted  in  the  cut. 

An  apparatus,  the  mech- 
anism of  which  is  some- 
what similar  to  tliis,  is  high- 
ly recommended  by  Mr. 
Reeves,  and  is  shown  in 
Fig.  727. 

The  mollification  of  Scar- 
pa's shoe  (Fig.  728)  possess- 
es some  advantages  over  the 

iron  shoe  above  described,  and  should  be  preferred   to  it  when  it  car) 
be  obtained. 

Tenotoimj  ^nii  fasciotomy  will  be  found  necessary  in  a  large  proi)or- 
tion  of  cases  of  talipes  equino-varus,  and,  when  not  es.sential  to  ultimate 
success,  it  will  greatly  expedite  the  permanent  restoration  of  the  mem 
ber  to  its  normal  i)osition.  The  application  of  Esmarcirs  bandage  from 
the  toes  to  above  the  knee,  though  not  essential,  renders  the  ojjei'atix  e 
procedure  more  rapid  and  easy  of  execution.  The  tendo  Achillis  is 
divided  as  heretofore  directed.  In  addition,  the  til)ialis  anticus  and  the 
til)ialis  posticus  will,  as  a  rule,  require  to  be  divided.  The  tendon  of  the 
tibialis  anticus  should  be  cut  sul)cutaneously  about  one  inch  above  its 
insertion  into  the  internal  cuneiform  bone  by  introducing  the  tenotome 
beneath  it  from  the  middle  line  of  the  foot.  It  can  be  made  prominent 
by  forcible  eversion  of  the  foot.     Division  of  the  tendon  of  the  tibialis 


Fig.  728. — Modified  Scarpa's  slioe  for  talipes  varus  and  equiii"- 
varui.     (Alter  Keevcs.) 


TALIPES   VARUS  AND   EQUINO-VARUS.  731 

posticus  is  best  effected  by  an  incision  parallel  with  the  inner  border  of 
the  tibia  just  above  the  internal  malleolus,  wliere  it  lies  in  close  relation 
to  this  surface  of  tiie  bone.  As  soon  as  it  is  exposed,  an  aneurism-needle 
should  be  passed  beneath  it,  v/hen  it  can  be  drawn  out  tlirough  the  wound 
and  divided  ^yith  the  scissors.  Subcutaneous  section  of  this  tendon  is 
a  very  difficult  and  uncertain  procedure,  while  no  mistake  is  possible 
through  au  open  wound.  If  careful  antisepsis  is  practiced,  and  if  the 
wound  is  at  once  closed  with  catgut  sutures,  no  suppuration  can  occur. 
The  plantar  fascia  should  be  divided  by  introducing  the  tenotome  flat- 
wise under  the  fascia  from  the  inner  border  of  the  foot,  turning  the  edge 
outward,  and  cutting  the  fascia  as  it  is  made  tense.  Several  lines  of 
section  through  this  fascia  may  be  made  when  necessary.  Bits  of  adhe- 
sive plaster  should  be  j^laced  over  each  puncture. 

Tarsotomy. — In  exaggerated  auil  chronic  cases  of  congenital  talipes 
eqnino-varus,  a  wedge-shaped  exsection  of  a  portion  of  the  tarsus  will 
at  times  permit  a  restoraticju  of  the  foot  to  its  normal  position,  and  serve 
to  restore  in  great  part  the  usefulness  of  the  member.  In  two  recent 
cases  in  which  I  performed  this  operation,  the  most  gratifying  results 
were  obtained.  In  each  case  the  patient  walked  with  the  dorsum  of  the 
foot  on  the  floor,  and,  in  one  instance,  the  toes  pointed  directly  back- 
ward. 

After  Esmarch's  bandage  has  been  applied,  a  free  incision  is  made 
along  the  fibular  side  of  the  foot,  extending  from  below  the  external 
malleolus  to  the  tarso-metatarsal  junction.  All  the  tissues  should  be 
lifted  from  the  bones  by  the  periosteal  elevator,  and  the  wedge-shaped 
section  of  the  tarsus  removed  by  the  gouge  or  chisel.  The  anterior  por- 
tion of  the  astragalus  wUl  require  to  be  removed,  and  as  much  of  the 
tarsus  should  be  exsected  as  is  needed  to  permit  the  restoration  of  the 
foot  to  the  natural  position ;  for  it  is  not  only  neces.sary  to  evert  the 
foot,  but  to  make  at  the  same  time  a  marked  rotation  of  that  part  of 
the  member  anterior  to  the  line  of  section.  The  tendo  Achillis  should 
now  be  divided,  and,  as  soon  as  the  proper  position  is  obtained,  the 
wound  should  be  irrigated  with  sublimate  solution,  the  incision  closed 
and  covered  with  iodoformized  gauze,  and  a  light  sublimate  dressing 
and  compression-bandage  applied  tight  enough  to  arrest  all  oozing.  A 
plaster-of-Paris  dressing  is  now  put  on,  and  the  foot  held  in  position 
until  this  hardens.  This  last  procedure  can  be  facilitated  by  adjusting 
two  strips  of  adhesive  plaster,  one  of  which  will  serve  to  hold  the  foot 
at  a  right  angle  to  the  axis  of  the  leg,  and  the  other  to  keep  it  rotated 
outward  while  the  plnstiH-  is  being  a]iplied  and  is  hardening.  The  dress- 
ing may  be  removed  not  earlier  than  the  tifteenth  day,  and  should  not 
be  disturbed  for  a  month  unless  from  soiling  or  smelling  it  is  necessi- 
tated. 

Talipes  Valgus.— \\\  this  deformity  the  normal  arch  of  the  foot  is 
lost,  and  the  foot  is  everted  (Figs.  729,  730,  731,  732).  The  contracted 
muscles  are  the  ]ieroneus  longus  and  brevis,  while  the  i>aralysi.s,  as  a 
rule,  affects  the  tibialis  posticus,  anticus,  and  flexor  muscles.  When  the 
tarsal  arch  gi\es  way,  the  plantar  fascia,  calcaneocuboid  ligaments,  and 


732 


A  TEXT-1500K   ON  SURGERY. 


short  flexors  become  stretched,  and  the  tibialis  anticiis  is  elongated.    The 
yielding  of  these  nauscles  may  be  due  to  paralysis,  or  to  strain  from  the 


habit  of  carrying  heavy  -weights. 


Flo.  729. — Conjenital  t.alipes  valgus. 
(After  Churohill.j 


Fio.  730. — Acquired  talipes  valgus. 
(After  Churchill.) 


Fig.  7.31. — Inner  view  of  a  severe  v.ilffus  of  tlie  right  fint. 
(.\fter  Reeves.)  ],  Inner  malleolu.s.  i.  Inner  surface 
of  head  of  astragalus.     3,  Tubercle  of  scaphoid. 


Treatment. — Tn  talij)es  val- 
gus in  an  infant  the  eversion 
may  be  corrected  by  means  of 
the  adhesive  strips  applied  as 
in  the  ti'eatment  of  varus.  The 
direction  of  traction  is  of 
course  opposite.  The  artificial 
muscles,  after  the  method  of 
Barwell,  are  also  as  applicable 
here  as  in  varus.  The  iron 
shoe  (Fig.  725),  made  with  the 
bar  to  come  upon  the  inner 
side  of  the  leg,  is  as  service- 
able in  mild  cases  of  valgus  as 
in  varus  or  equino- varus.  This 
apparatus  is  always  worn  in- 
side of  an  ordinary  shoe.  Ny- 
rop's  boot  (Fig.  733)  is  highly 
recommended  by  Mr.  Reeves. 
It  consists  of  a  stiff-soled  lacing- 
shoe,  with  a  leg-collar  and  iron 
or  steel  bar  attached  to  the 
outer  side  of  the  shoe,  with  a 
lateral  hinge  opposite  the  out- 
er malleolus.  To  the  inner  side  of  the  sole,  near  the  heel,  is  attached  a 
strong  piece  of  elastic  webbing,  l)y  which  inversion  of  the  foot  is  effected 
by  buckling  the  strap  to  the  collar  near  the  knee. 


Flo.  732. — Inner  view  of  the  bones  of  a  severe  valgus. 
l'.\ttcr  Reeves.  I  1,  Tubercle  of  smiphoid.  2,  Astrag- 
alus. 3,  Os  calcis.  4,  Internal  cuneiform  bone.  0, 
First  metatarsal. 


TALIPES  CAVUS.— TALIPES  PLANUS.  733 

'V\Tieii  tenotomy  of  the  peronei  muscles  is  indicated,  they  should  be 
divided  subcutaneously  from  three  quarters  to  one  and  a  half  inch  (ovping 
to  the  age  of  the  ijatient)  above  the  external  malleolus.     Cuneiform  tar- 
sotomy may  be  ajiplied  to  the  correction  of  this  de- 
formity in  exaggerated  cases  in  adults.     When  the 
bones  are  thoroughly  ossified  it  will  be  impossible  to 
change  the  shape  of  these  organs  and  restore  the 
normal  shai:)e  of  the  part  by  any  mechanical  appa- 
ratus, no  matter  how  persistent  in  its  use.     The  in- 
cision is  made  along  the  inner  side  of  the  foot,  and 
the  apex  of  the  conical  section  must  be  at  the  outer 
border  of  the  tarsus.     The  details  of  the  operation 
and  the  after-treatment  are  practically  the  same  as 
given  for  equino-varus. 

Talipes  CavKS. — Hollow-foot  is  almost  always  an 
acquired  deformity,  although  it  may  be  congenital. 
It  occurs  with  talipes  calcaneus,  equinus,  and,  in  a     fic.  733.— Nyrop-s  shoe 
mild  degree,  may  complicate  varus  and  equino-varus.  (After''Eecves  T"'^'"*' 

In  this  deformity  the  antero-posterior  arch  of   the 
foot  is  exaggerated,  the  plantar  fascia  and  the  muscles  of  the  plantai' 
region   which   have   their   origin  behind   the   medio-tarsal    joint,    and 

are    inserted    anterior  to   this  articula- 
tion, are  shortened.     The  plantar  fascia 
'•  '^  and  the  calcaneo- cuboid  ligaments  are 

>,  '  also  shortened.     The  sole   of    the  foot 

-_   —  -*  no  longer  rests  upon  the  floor,  as  in  the 

Fio.  T34.-Showine  the  surface  of  the  sole     normal  Condition  (Fig.  734),  but  touch- 

fooi''\Aft'erTyrelr  "°°'"  "'" °°™'''     es  Only  at  the  heel  and  along  the  meta- 

tarso-phalangeal  line. 

Any  inflammatory  process  of  the  plantar  region  may  induce  contrac- 
tion of  the  fascia  or  ligaments  ;  or  spastic  contraction  of  the  muscles  of 
this  region  from  local  or  remote  causes  may  produce  this  deformity.  Com- 
mencing before  the  bones  are  softened,  the  distortion  of  the  foot  is  apt 
to  become  i^ermanent  unless  exsection  or  crushing  is  perfomied.  Of 
these  two  procedures,  tarsoclasis  is  the  most  readily  accomplished ; 
but,  when  the  tarsoclast  can  not  be  had,  section  through  the  tarsus, 
with  a  thorough  division  of  the  plantar  fascia,  will  be  justifiable.  For- 
tunately, few  instances  will  occur  where  such  harsh  procedures  will  be 
called  for. 

In  recent  cases  the  deformity  may  be  relieved  by  wearing  a  plain  shoe 
with  a  low,  broad  heel  and  straight,  thick  sole.  The  plantar  fascia 
should  be  divided  in  all  cases  which  do  not  readily  j'ield  to  mechanical 
treatment. 

Tal'qjes  Planns. — Flat-foot  has  been  partially  considered  with  talipes 
valgus,  with  which  condition  it  is  almost  always  associated.  The  antero- 
posterior arch  of  the  foot  is  more  or  less  obliterated,  and  in  severe  cases 
the  anterior  portion  of  the  sole  spreads  out  or  widens  in  its  transverse 
diameter  (Fig.  73j). 


734 


A  TEXT-BOOK  ON   SURGERY. 


Fio.  735.— Cast  of  the  r'yiit  foot  in 
case  of  talipes  planus,  at  tbe  Poly 
clmlc. 


The  plantar  fascia  and  calcaneo-cuboid  ligaments  are  stretched,  the 
internal  lateral  ligaments  of  the  ankle-joint  are  generally  involved,  while 
the  tibialis  anticus  and  the  antero-jjosterior  muscles  of  the  jtlantar  as- 
pect of  the  foot  are  elongated.  Tlie  jirinci- 
pal  cause  of  this  deformity  is  the  habitual 
carrying  of  heavy  burdens,  or  }iressure  of 
tile  superincumbent  weight  of  the  body  upon 
the  arch  of  the  foot,  together  with  lack  of 
tonicity  in  the  muscles,  and  of  strength  in 
the  ligaments  and  fascia. 

Treatment. — It    is    exceedingly    difficult 

and  in  the  majority  of  cases  im])ossib]e  to 

con-ect  this  deformity.     The  best  method  is  to  support  the  arch  of  the 

foot  by  a  comfortable  adjustment  of  pressure  by  inserting  a  piece  of  felt 

in  the  sole  of  the  shoe,  just  beneath  the  arch. 

The  deformities  of  the  toes  are  congenital  and  acquired.  The  con- 
genital deviations  from  tlie  normal  are  the  presence  of  one  or  more  su- 
pernumerary toes  {polydactylus)^  or  the  absence  of  one  or  more  of  these 
members  {si/ndactylus). 

In  polydadytus  the  most  frequent  supernumerary  toe  is  one  connected 
with  the  great-toe,  attached  usually  on  its  inner  or  tibial  aspect,  near  the 
junction  of  the  metatarsal  bone  and  phalanx.  In  a  rare  case  of  this  de- 
formity, reported  by  Prof.  Sayre,  there  were  eight  toes  on  the  right  and 
ten  on  the  left  foot. 

Treatment.— AW  minor  deformities  the  removal  of  which  does  not 
endanger  the  life  of  the  individual,  or  diminish  the  usefulness  of  tlie 
member  affected,  demand  amputation  within  the  first  year  or  two  of  life, 
before  the  patient  is  old  enougli  to  become  conscious  of  possessing  a  de- 
formity. 

Syndactylus  is  a  term  applied  not  only  to  the  partial  or  entire  ab- 
sence of  one  or  more  fingers,  but  also  to  the  condition  known  as  congen- 
ital iceb-toe. 

Web-toes  may  be  treated  in  tlie  same  way  as 
web-fingers.  If  neglected  until  the  child  is  old 
enough  to  become  accustomed  to  the  deformity, 
operation  is  of  doubtful  proj^riety. 

When  one  or  more  toes  are  missing,  as  in  Fig. 
736,  even  when  the  deformity  is  offensive  to  the 
sight,  the  question  of  operative  interference  (except 
for  relief  from  pain)  should  depend  upon  the  de- 
gree of  usefulness  enjoyed  by  the  deformed  mem- 
ber. An  important  principle  in  the  surgery  of  the 
foot  is  to  save  every  particle  of  surface  for  the  sup- 
port of  the  body.  This  conclusion  gains  additional  force  in  the  ability 
to  conceal  the  deformity  by  a  properly  constructed  shoe. 

The  acquired  deformities  of  the  toes  result  in  almost  all  cases  from 
improperly  adjusted  shoes.  The  displacement  may  be  in  all  directions, 
although  those  of  the  great  and  little  toes  are  usually  toward  the  median 


Fig.  Vol). — S.yiidactylus  in 
the  right  foot  of  a  boy. 
(After  Reeves.) 


HALLUX  VALGUS. 


735 


line  of  the  foot.     The  middle  toes  may  be  flexed  in  one  joint,  extended 
in  another,  or  crossed  over  each  other. 

Hallux  valgus,  or  displacement  of  the  great-toe  toward  the  hbular  or 
outer  side  of  the  foot,  is  a  common  deformitj^  (Fig-  738).  In  exagger- 
ated instances  mechanical  or  surgical  interference  is  demanded.  Hallux 
valgus  is  caused  chiefly  by  shoes  which  are  i)ointed  at  the  tip  and  are  too 
short  for  the  foot.  It  may  also  occur  with  club-foot,  and  generally  with 
talipes  varus  and  planixs.  The  action  of  the  muscles  inserted  into  the 
base  of  the  great-toe  must  not  be  altogether  overlooked  in  the  jetiology 
of  this  deformity.  Of  the  tive  muscles  which  arise  from  the  tarsus  and 
metatarsus  and  ai-e  inserted  into  this  toe,  all  but  one  tend  to  cany  it  to- 
ward the  fibular  side  of  the  foot. 

In  being  displaced,  the  great-toe  usually  is  carried  above  the  second 
or  third  toe,  occasicmally  beneath  it.  The  phalanx  is  more  or  less  com- 
pletely dislocated  from  the  original  articular  surface  of  the  metatarsal 
bone,  being  twisted  around  to  its  outer  lateral  aspect.  The  cartilage  of 
the  old  portion  disappears,  and  a  new  joint-surface  is  developed  on  the 
external  aspect  of  the  metatarsal  bone.  From  pressure,  a  callosity  of 
varying  thickness  develops  over  the  tip  of  the  metacarpus,  adding  greatly 
to  the  appearance  of  deformity. 

Treatment. — Mild  cases  of  hallux  valgus  may  be  cured  by  elastic  ten- 
sion steadily  applied,  as  follows :  A  soft  kid  or  chamois-skin  cover  is 

made  for  the  affected  toe,  and  to  the  end  of 
this  a  piece  of  thin  elastic  webbing  is  at- 
tached. To  the  webbing  a  strip  of  adhesive 
plaster  is  stitched,  and  this  is  earned  around 


the  heel  and  is  made  to  adhere  along  the 


Fig.  VST. — Savro's  aietlind  of  treating 
liallux  vaigiis.     (At\er  Sayrc.) 


Fig.  738.— Hallux  valgus.     (From  a 
patient  at  Mount  Sinai  Hospital.) 


Fio.  739.— The  same, 
alter  operation. 


outer  side  of  the  foot  in  such  a  way  that  the  webbing  is  made  to  draw 
the  toe  outward  (Fig.  737). 

In  severe  ca.ses,  operative  interference  can  alone  restore  the  toe  to  its 
normal  position.  The  operation  consists  in  an  incision  made  along  the 
inner  side  of  the  foot,  the  center  of  which  is  over  the  angular  projection 
at  the  end  of  the  metatarsal  bone.  The  callosity  should  be  removed,  the 
Joint  opened,  a  wedge-shaped  segment  removed  from  the  end  of  the 
metatarsal  bone  and  tlie  phalanx.  Enough  should  be  removed  with  the 
oxsector  or  metacarjial  saw  to  permit  the  bones  to  be  brought  into  jiroper 


736  A   TKXT-BOOK   ON  SURGERY. 

position,  where  they  should  be  lield  by  a  silver-wire  suture  passed  welll 
into  tlie  bon(^  a  liiilf-iiich  from  the  cut  surface;  or  the  bones  ni:iy  be  held 
in  apijosition  by  transhxion  Avitli  small  steed  drills.  Fi<;.  738  is  from  a 
cast  taken  from  a  jiatient  at  Mount  Sinai  Hospital  upon  wlumi  I  did  this 
operation  in  both  feet.     The  degree  of  cori'ection  is  shown  in  Fig.  730. 

This  operation  is  preferable  to  that  of  osteotomy  of  the  lii-st  metatar- 
sal bone  just  behind  the  articulation,  for  the  reason  that  the  callosity 
and  projection  ojtposite  the  joint  can  only  be  removed  by  excision. 

Hallux  rants,  or  pigeon-toe,  is  a  much  rarer  deformity,  and  occurs 
usually  as  a  result  of  cicatricial  contractions  or  from  sjjastic  action  of 
the  abductor-pollicis  muscle.  The  treatment  consists  in  adjusting  a  well- 
made  shoe  which  will  push  the  toe  into  its  proper  position.  Division 
of  any  cicatricial  tissue  or  the  tendon  of  the  abductor  muscle  may  be 
necessary. 

Disphicemi'id  of  the  little  toe  is  usually  inward  and  beneath  the 
fourth.  The  same  treatment  may  be  ap^tlied  in  this  deformity  as  given 
for  hallux  valgus. 

Flexion  of  the  toes  may  be  com])lete  when  there  is  ]iaralysis  of  the 
extensor  muscles.  The  most  usual  form  is  that  in  which  the  lirst  phalanx 
is  tilted  upward,  that  is,  seemingly  extended,  while  the  distal  phalanx  is 
drawn  downward,  so  that  the  nail  is  to  the  front,  and  the  tij)  of  the  toes 
rests  upon  the  ground.     This  condition  is  also  known  as  Jiainiaer-toes. 

The  cause  is  chiefly  one  of  improper  shoeing,  by  which  the  toes  are 
not  allowed  to  be  fully  extended,  and,  being  held  in  this  cramped  position 
by  the  shoe,  the  muscles  and  fascia)  b-ecome  permanently  shortened.  The 
plantar  fascia  is  usually  involved  in  chronic  cases.  The  extensor  mus- 
cles become  shortened  as  well  as  the  flexors,  which  are,  however,  tlie 
principal  agents  in  producing  the  deformity. 

Extension  of  the  toes  beyond  the  normal  line  is  a  rare  condition.  It 
could  only  be  caused  by  paralysis  of  the  flexors. 

Treatment. — In  mild  cases  of  incipient  hammer-toes  a  cure  may  be 
effected  by  wearing  a  shoe  long  enough  to  allow  these  nu'ml)ei-s  to  be 

extended.  In  more  chronic  and  obstinate  cases, 
a  metal  sole  should  be  adjusted  so  that  an  ordi- 
nary shoe  can  be  worn  over  it.  Just  beneath  the 
middle  of  the  toes  is  a  series  of  perforations  in 
the  sole,  through  which  loops  are  ])assed.  The 
toes  are  straightened  by  traction  on  the  loops, 
which  are  tied  below  (Fig.  740).     In  some  in- 

FiG.  740.— Aiipuratiis  for  hum-  .  ,  ,  r   ^^       -x  a  i  ^ 

mer-toe3.   (.\rter  Keeves.)        stauces  tenotomy  of  the  long  flexor  and  extensor 

muscles  and  of   the   plantar  fascia  is  essential. 

The  tendons  of  the  extensor  digltorum  should  be  subcutaneously  divided 

just  over  the  bases  of  the  toes  ;  the  flexor  tendons  near  the  middle  of  the 

j)lantar  surface  of  these  members. 

Bunions  are  callosities  resulting  from  intermittent  pressure  upon  cer- 
tain portions  of  the  foot. 

Corns  are  both  hard  and  soft.  A  hard  corn  differs  from  a  bunion 
only  in  size.     Soft  corns  are  small  ulcers  situated  between  the  toes  or  in 


IN-GROWING  NAIL.  737 

the  fissures  on  the  under  surface.  They  are  caused  by  friction  of  opposing 
surfaces  and  moisture. 

Bunions  and  hard  corns  are  to  be  treated  by  relieving  the  unnatural 
pressure  which  caused  them.  Comfortably  fitting,  yet  not  necessarily 
loose  shoes,  of  soft  leather,  should  be  worn.  Pieces  of  Canton  flannel, 
cut  into  rings  and  laid  uj^on  each  other  so  that  the  pressure  will  be  dis- 
tributed to  the  surfaces  near  the  corn,  will  be  advisable,  in  simple  cases, 
even  when  loose  shoes  are  adopted.  A  small  tuft  of  cotton  dipped  in 
vaseline  will  aid  in  softening  the  hard  covering.  Soft  corns  may  be 
readily  cured  by  inserting  jiellets  of  absorbent  cotton  moistened  with 
borax  dissolved  in  glycerine,  and  applied  so  as  to  protect  the  raw  sur- 
faces and  prevent  friction. 

In-growing  nail  is  one  of  the  commonest  affections  of  the  feet,  and  is 
almost  always  met  with  in  the  great  toe.  The  palliative  treatment  is  to 
cut  away  portions  of  tlie  nail  near  the  infiamed  surface  and  protect  this 
by  a  small  pellet  of  lint  mcdstened  in  the  borax  and  glycerine  mixture. 
The  employment  of  cocaine,  however,  enables  the  surgeon  to  remove  the 
offending  nail  without  a  particle  of  pain,  and  in  this  way  a  pennanent 
and  radical  cure  is  readily  effected.  I  have  performed  this  operation 
repeatedly  after  the  foUovdng  method :  The  foot  and  toes  should  be 
cleansed  and  thoroughly  disinfected.  An  elastic  ligature  should  be 
thrown  around  the  toe,  as  close  to  the  metatarsal  junction  as  possible. 
The  anaesthesia  is  effected  by  introducing  the  hypodermic  needle  of  the 
cocaine-syringe  beneatli  the  skiu  on  the  dorsum  of  the  toe,  half  an  inch 
behind  the  nearest  surface  of  the  nail — i.  e.,  just  about  the  posterior  bor- 
der of  the  matrix.  Three  or  four  drops  of  a  4-per-cent  solution  are  forced 
out  here  and  the  needle  pushed  under  the  skin,  to  right  and  left,  until 
from  fifteen  to  twenty  minims  have  been  injected  across  the  toe  and  on 
either  side  of  the  nail  toward  the  tip.  of  the  toe.  The  line  of  this  injec- 
tion is  in  the  shape  of  a  horseshoe.  The  needle  should  now  be  removed, 
and  reinserted  through  the  anaesthetized  skin,  and  carried  thence  subcu- 
taneously  until  the  anaesthesia  is  complete  at  all  points  around  the  nail. 
Forty  minims  of  a  4-per-cent  solution  may  be  employed.  In  from  three 
to  five  minutes  insensibility  is  perfect.  An  incision  is  first  made  from 
the  middle  of  the  posterior  margin  of  the  nail  directly  backward  for  half 
an  inch.  A  second  incision  across  the  top  of  the  toe,  extending  as  low 
down  as  the  most  inferior  portion  of  the  nail,  on  either  side,  uniting  the 
perpendicular  cut,  gives  the  entire  wound  a  T-shape.  The  two  quadri- 
lateral flaps  f)f  skin  are  now  dissected  up,  turned  one  to  the  right  and 
one  to  the  left  side,  and  held  away  by  the  weight  of  an  artery-forceps  or 
by  retractors.  The  nail  should  next  be  split  from  before  backward  in 
the  middle  line,  the  incision  extending  through  the  matrix  as  far  back  as 
the  transverse  incision  through  the  skin.  Botli  halves  and  the  matrix 
should  be  thoroughly  extirpated,  all  granulation-tissue  scraped  out,  and 
the  foot  dipped  into  a  basin  of  warm  sublimate  solution,  1-2000.  At 
this  juncture  tlie  ehistic  tourniquet  should  be  removed,  and  the  wound 
allowed  to  bleed  for  a  minute.  By  this  means  the  excess  of  cocaine  solu- 
tion is  washed  out  of  the  tissues.  The  ligature  should  then  be  reapplied. 
47 


738 


A  TEXT-BOOK   ON   SURGHRY. 


The  flaps  arc  now  brought  info  ])()siti()n,  the  spac(f  foriiH  ily  occupied  by 
the  horny  i)art  of  the  nail  paclvecl  with  sublimate  f^auzp,  and  the  entire 
toe  enveloped  in  the  same  material.  A  narrow  bandage  should  be  applied 
finnly  enough  to  hold  the  gauze  in  place,  and  to  exercise  sufficient  com- 
pression to  prevent  bleeding.  Over  this  a  generous  jiiece  of  jjrotective 
should  be  thrown  and  a  second  bandage  applied.  When,  in  applying 
this  bandage,  the  elastic  ligature  is  reached,  it  should  be  tak<ni  oil"  and 
the  roller  carried  on  to  the  foot.  A  single  dressing  usually  suffices,  and 
it  need  not  be  removed  for  ten  days  or  two  weeks. 

Deformities  of  the  Upper  Extremity — Ctfrvicle. — Congenital  absence 
of  portions  of  one  or  both  of  these  bones  may  exist.  No  case  of  complete 
absence  of  the  collar-bone  is  as  yet  on  record.  The  partial  deficiency 
may  occur  on  one  or  both  sides,  and  is  usually  at  the  inner  extremity. 
The  indications  in  treatment  are  to  use  a  figure-of-8  brace  around  the 
slioulders  to  prevent  them  from  Iw'ing  approximated  in  part  by  the 
a('tions  of  the  pectoral  muscles. 

Parab/sis  of  the  deltoid  and  serratus  inagniis  muscles  imparts  to 
the  shoulder  a  deformed  a])pearance.  In  deltoid  paresis  the  shoulder  is 
flattened,  and  the  acromion  process  more  prominent  and  easily  recog- 
nized. The  arm  is  incapable  of  being  lifted  to  a  right  angle  with  the 
spine.  It  may  be  due  to  injury  of  the  circumflex  nerve,  or  to  a  cen- 
tral nervous  lesion.  When  the  serratus  magnus  is  paralyzed,  the  ver- 
tebral border  of  the  scapula  is  tilted  outward  in  a  jjosition  of  unusual 
prominence.     Neither  of  these  injuries  is  amenable  to  surgical  treatment. 


Fio.  741.— Con^eiiHal  fusion  of  the  radius  and  ulna.     (l'"r"in  a  case  at  the  Polyclinic.) 


Anchylosis  of  the  shordder  is  more  amenable  to  the  operation  of  ex- 
secticm  than  to  forcible  breaking  up  of  the  adhesions.  This  last  proced- 
ure may  be  employed  in  cases  of  i^artial  anchylosis  in  which  no  inflam- 


ANCHYLOSIS. 


739 


matory  process  is  going  on.     In  anchylosis  of  the  elbow-joint  the  same 
treatment  is  advisable. 

Deformities  of  the  forearm  are  conqiaratively  rare.  Of  the  congenital 
variety,  occasionally  there  exists  a  fusion  of  the  two  bones.  The  length 
of  the  forearm  is  normal,  as  is  the  motion  at  the  elbow-joint,  but  supi- 
nation and  pronation  are  impossible.  In  the  only  case  I  have  ever  seen, 
from  which  Fig.  741  is  taken,  the  hands  were  in  the  prone  position.  Op- 
erative interference  was  not  indicated  in  this  instance. 


Fig.  742. — Deformity  resultuij;  from  subperiosteal  e.fseetion  of  the  entire  radius  for  ostitis.     (From  a  case 

operated  on  at  tlie  Polyclinic.) 

Distortions  due  to  rickets  are  at  times  met  with,  and  may  result  from 
the  action  of  the  muscles  upon  the  softened  bones,  or  to  pressure  from 
the  habitual  carrying  of  burdens  in  the  hands.  In  destruction  of  one  of 
the  bones  of  the  forearm  by  ostitis,  or  after  its  removal,  deformity  usually 
results,  the  deviation  of  the  hand  being  toward  the  side  of  the  missing 
bone  (Fig.  742). 

Treatment.— In  deformity  after  rickets,  correction  by  osteotomy  is 
justifiable  after  the  disease  is  arrested.  Iti  the  distortions  due  to  loss  of 
substance  there  is  little  hope  of  relief.    If  the  loss  on  one  side  is  limited. 


740  A  TEXT-BOOK   ON   SURGERY. 

exsection  of  a  portion  of  the  sound  bone  and  reunion  of  tlie  divided  sur- 
faces by  wire  sutures  might  be  entertained. 

Cluh-JIand. — Distortions  of  the  hand,  not  unlike  those  ah'eady  de- 
tailed as  occurring  in  tlie  foot,  yet  far  less  common,  may  be  met  with. 
The  deformity  may  be  at  the  wrist-joint,  in  the  intercarpal  or  carpo- 
metacarpal niticulations,  and  may  be  due  to  failure  of  develo])ment  in 
the  bones  of  the  forearm  or  hand,  to  muscular  paralysis,  to  fracture, 
dislocations,  or  cicatricial  contractions. 

In  the  congenital  deficiencies,  the  radius  is  more  often  wanting,  or 
only  partially  developed,  allowing  the  hand  to  be  carried  toward  the  ra- 
dial side.  The  carjias  is  occasionally  deficient.  Not  infrequently  the 
congenital  cases  are  symmetrical,  and  the  lower  extremities  are  also  in- 
volved. 

The  muscles  are  deficient  in  some  of  these  cases  of  osseous  maKorma- 
tion.  The  usual  condition  in  paralysis  is  that  of  flexion  of  the  carpus 
and  metacarpus  upon  the  forearm. 

This  variety  is  termed  palinar  ;  the  opposite,  dorsal  club  -  hand. 
When  the  displacement  is  lateral  it  is  called  radial  or  ulnar,  as  the  hand 
is  carried  outward  or  inward.  As  in  club-foot,  there  are  compound  forms 
of  club-liand. 

As  to  frequency  in  the  congenital  types,  the  radius  being  chiefly  at 
fault,  the  radial  distortion  is  most  frequent.  When  from  any  cause  the 
equilibrium  between  the  muscles  is  impaired,  the  hand  is  usually  flexed 
upon  the  forearm,  and  the  condition  is  known  as  palmar  club-hand. 
With  this  there  may  be  radio-palmar  or  ulno-jjalmar  deformity. 

Fracture  of  the  radius  (CoUes's),  or  epiphyseal  separation,  may  induce 
a  mild  form  of  radial  club-hand.  Unreduced  dislocations  will,  of  course, 
cause  deformity.  Deformities  due  to  cicatricial  contraction,  as  after 
burns  (Fig.  148),  extensive  phlegmons,  etc.,  are  occasionally  met  with. 

The  treatment  of  all  these  different  varieties  of  club-hand  will  depend 
upon  the  particular  cause.  In  the  worst  form  of  congenital  deformity, 
amputation  at  or  shortly  after  birth  should  be  performed.  Other  and 
milder  cases  may  be  improved  by  mechanical  apparatus  constructed  to 
meet  the  indications. 

In  muscular  paralysis  the  same  general  rules  of  practice  as  laid  down 
in  club-foot  due  to  this  cause  should  be  followed.  Ttinotomij  may  be 
necessary.  The  extensors  may  be  subcutaneously  divided  about  the 
middle  of  the  metacarpal  bones.  The  flexors  slightly  above  the  wrist- 
joint.  The  lateral  deformities  also  will  justify  in  some  cases  division  of 
the  contracting  muscles.  The  rule  to  be  followed  is  to  do  subcutaneous 
tenotomy  when  the  tendon  to  be  divided  is  far  enough  away  from  any 
important  nerve  or  vessel  to  allow  a  perfectly  safe  and  sure  division  of 
the  tendon  ;  if  not,  the  tendons  should  be  exposed  by  incision  under 
strict  antisepsis,  and  each  one  picked  up  on  an  aneurism-needle  and 
divided  in  plain  view. 

The  propriety  of  breaking  up  adhesion  in  anchylosis  with  malposition, 
or  of  resection,  should  ])e  determined  by  the  condition  of  the  parts  and 
of  the  patient,  and  the  necessities  of  the  case. 


THE   FINGERS  AND  HAND. 


741 


TTie  Fingers  and  I/and.— Among  the  congenital  deformities  of  the 
fingers  are  polydactylus,  syndactylus,  and  web-finger,  or  fusion  of  two 
or  more  digits.  The  acquired  deformities  are  diie  to  contraction  of  the 
palmar  fascia,  of  the  muscles  and  tendons,  to  paralysis  of  certain  mus- 
cles, and  to  osseous  and  articular  lesions,  both  traumatic  and  idiopathic. 

Supernumerary  Finger  {Poli/dactylus). — The  usual  location  of  one 
extra  finger  is  on  the  radial  side  of  the  thumb  or  ulnar  asjiect  of  the 
little  finger,  near  the  metacarpo-phalangeal  junction  (Fig.  743).  It  may 
or  may  not  possess  phalanges  or  cartilages.  If  the  phalanges  exist,  a 
synovial  cavity  will  be  found  at  the  junction  with  the  metacarpal  bone, 
or  with  the  phalanx  of  the  normal  member. 


Fig.  7-43. — Supernumerary  digits.     (After  Eeeves.) 


Fig.  744. — Double  hand.     (After  Reeves.) 


A  rare  form  of  supernumerary  fingers  is  shown  in  Fig.  744,  in  which 
there  is  practically  a  double  hand.  Amputation  of  the  supernumerary 
members  should  be  made  soon  after  birth. 

In  syndactylus,  all  or  a  portion  of  one  or  more  fingers  may  be  want- 
ing (Fig.  74o).    Amputation  of  the  deformed  portion  is  usually  advisable. 

Web-finger  is  usually  congenital,  although  it  may  be  acquired.  In 
mild  cases,  where  the  union  between  the  contiguous  surfaces  is  slight, 


Fig.  745.- 


■Stunted  and  webbed  hand. 

(After  Reeves.) 


Fio.  746. — Eliustic  liirature  pasi*ed  tlirousli  the  web. 
(AtUr  Fort  and  Noble  Smith.) 


and  the  web  is  thin,  the  following  method  will  succeed :  A  round  elastic 
ligature  or  cord  is  carried  through  the  web  just  in  front  of  the  metacarpo- 
phalangeal articulation,  and  the  ends  are  turned  back  and  attached  to 
a  band  around  the  wrist  (Fig.  746).     This  is  allowed  to  remain  fur  three 


742 


A  TEXT-HOOK   ON  SURGKRV. 


or  four  weeks,  until  the  hole  made  by  the  lij^ature  is  lined  with  epider- 
mis. A  second  punrture  should  now  be  made  al)ont  one  inr-h  in  front  of 
the  tirst,  the  ligature  jiassed  through  tliis,  and  the  ends  tied.  The  con- 
stant traction  of  the  elastic  gradually  cuts  through  the  web,  yet  so  slowly 
that  the  track  of  the  wound  becomes  covered  with  e])idermis.  This  pro- 
cedure should  be  repeated  until  all  the  web  is  divided. 

When  the  lingers  are  solidly  united,  the  method  of  Didot  should  be 
preferred.  An  incision  is  made  down  the  palmar  surface  of  one  linger 
(the  index.  Fig.  747)  and  along  the  dorsal  surface  of  the  adjoining  mem- 
ber (the  middle!  linger).  The  flaps  are  dissected  up  so  that  the  one 
removed  from  the  palmar  surface  of  the  index-finger  remains  attached  to 
the  middle  finger,  while  the  posterior  flap  is  attached  along  the  dorsnm 


of  the  index-linger. 


They  are  then  sutured  in  position  (Fig.  748j. 


Fi3.  147. — Ditlot's  method  of  operating  for 
wcb-fingera.  (Alter  Fort  and  Noble 
Smitli.) 


Flo.  74S. — Transverse  sccti'ms  of  the  webbed 
fingers,  shoHini;  in  tbe  upper  figure  the 
line  of  separation  between  the  two  flaps ; 
in  the  middle,  the  outline  of  the  sepa- 
rated flaps ;  below,  the  sutures  are  ap- 
plied.    (After  i'ort  and  Noble  Smith.) 


In  those  cases  in  which  the  bones  are  only  slightly  united,  the  line  of 
union  may  be  sawed  through.  When  the  bones  are  fused  into  one  solid 
mass,  an  operation  is  not  indicated. 

Chronic  flexion  of  one  or  more  fingers  may  result  from  paralysis  of 
the  extensor  muscles,  spastic  contraction  of  the  flexors,  or  to  contractions 
of  the  palmar  and  digital  fascia.  Paralysis  of  the  extensors  may  be 
temporary  or  permanent.  Lead-poisoning  not  infrequently  leads  to  tem- 
porary impairment  of  the  function  of  this  group  of  muscles. 

In  neglected  cases  of  chronic  extensor  paralysis,  permanent  shorten- 
ing of  the  opposing  muscles,  with  contraction  of  the  palmar  fascia, 
occurs. 

The  indications  in  treatment  are  to  restore,  if  possible  the  functions 
of  the  paralyzed  muscles,  and  to  j^revent  defonnity  by  the  adjustment 
of  an  apparatus  which  will  keep  the  fingers  extended. 

Contraction  of  the  palmar  fascia,  as  a  result  of  any  inflammatory  pro- 


DUPUYTREN'S  CONTRACTION.— SNAP-FINGER. 


74;5 


cess,  gives  rise  to  the  most  common  deformity  of  the  lingers.     Penetrat- 
ing wounds  of  the  palm,  or  idioi)athi('  phlegmon,  are  exceedingly  aptto 

result  in  fascial  contraction  and  chronic  mal- 
position of  tlie  fingers. 

This  process  takes  place  at  times  in  per- 
sons of  the  gouty  or  rheumatic  diathesis  with- 
out any  marked  symptom  of  local  inflamma- 
tion.    The  tendons  are  not  affected,  as  a  rule, 


Fig.  749.  —  Dupuvtren's  con- 
tniction  in  tlie  fascia  of  tfie 
palm  and  of  the  little  fiager. 
(Alter  jSoble  Smith.; 


Fig.  750. — Tlie  same,  in  the  mickile  and  rinu  jinjcrs.  a,  Contract- 
ed hand  of  palmar  liiscia.  /',  Flexor  tcndojis  (not  involved t. 
c,  .Sheath  of  tendon.s.  f/,  r)i<:ital  prolonj^atioii.'i  of  palmar  fas- 
cia.    (After  W.  Adams  and  Noble  Smith.) 


in  the  earlier  stages  of  Dirpuytreii's  contraction.  In  old  cases  the  mus- 
cles are  shortened.  The  fascial  contractions  are  well  shown  in  Figs.  749 
and  750. 

Treatment. — In  mild  cases,  taken  early  in  the  commencement  of  the 
affection,  a  cure  may  be  effected  by  repeated  stretching  of  the  fascia  by 
fully  extending  the  fingers  involved.  In  obstinate  cases,  fasciotomy  is 
demanded.  Division  of  the  palmar  fascia  should  be  done  as  follows : 
The  hand  should  be  rendered  thoroughly  aseptic  by  washing  in  subli- 
mate solution,  and  rendered  bloodless  by  Esmarch's  bandage.  The  hy- 
podermic injection  of  4-per-cent  cocaine  solution  renders  the  operation 
painless.  The  delicate  fascia-knife  (Fig.  59)  should  be  introduced  be- 
neath the  bands  of  fascia,  which  can  be  made  prominent  by  extreme  ex- 
tension of  the  fingers,  the  edge  turned  upward,  and  a  thorough  division 
effected,  taking  care  not  to  allow  the  knife  to  cut  through  the  skin. 
Every  resisting  band  should  be  divided  until  the  fingers  can  be  readily 
brought  into  a  j^osition  of  over-correction.  Two  or  three  lines  of  section 
may  be  made  in  the  palm  and  one  or  two  through  the  digital  prolon- 
gations of  the  fingers  involved.  By  carefully  inserting  the  knife  closely 
beneath  the  fascia,  the  vessels  of  the  palm  and  fingers  may  be  avoided. 
The  palm  should  be  covered  with  a  thick  layer  of  sublimate  gauze,  and 
a  splint  applied  in  order  to  keep  the  fingers  perfectly  straight.  This 
should  be  worn  for  two  or  three  weeks,  at  which  time  passive  motion 
should  be  made  and  the  splint  reapplied  for  another  week.  After  it  is 
removed,  thorough  extension  should  be  practiced  at  least  once  a  day  for 
several  months. 

Snap-  or  Jerk-  Finger .—^h.\s  name  has  been  used  to  designate  a  condi- 
tion in  which  free  extension  and  flexion  of  one  or  more  fingers  is  more 
or  less  interrujited.     As  the  affected  digit  is  being  flexed  or  extended, 


744  A  TEXT-BOOK  OX   SURGERY. 

motion  is  arrested  in  a  certain  position,  and,  if  a  violent  effort  is  made, 
or  if  flexion  is  continued  l)y  aid  from  the  other  liand,  a  perceptible  jerk 
occurs  as  tlie  obstruction  is  overcome.  A  nodular  swelliuii;.  to  the  touch 
reseml)ling  the  ,iianglia  often  met  with  on  the  back  of  the  wrist,  may  be 
felt  along  the  line  of  the  tendon  at  or  near  the  metacariio-jihalangeal 
joint.  Snap-finger  may  be  due  to  a  circumscribed  thickening  of  the  ten- 
don, or  a  disproportion  between  the  size  of  the  tendon  and  sheatli  for  a 
limited  area.  This  condition  is  believed  to  exist,  especially  in  the  thumb, 
where  the  jerk  occurs  in  one  third  of  all  cases.  Mr.  Reeves  thinks  that 
in  the  tiiigers  it  is  chiefly  due  to  the  synovial  fringes  catching  upon  the 
transverse  process  of  the  palmar  fascia.  This  may  occnr  not  only  "from 
thickening  of  this  process  of  fascia,  but  also  from  rolling  up  or  displace- 
ment of  the  synovial  sheaths." 

Snap-finger  may  be  traumatic  or  idiopathic  in  origin.  Strains  on  the 
tendons  and  fascia  in  the  act  of  lifting,  direct  violence,  as  well  as  the 
gouty  and  rheumatic  inflammations,  are  noted  in  the  aetiology.  The 
treatment  consists  in  passive  motion,  and  internal  medication  to  correct 
any  dyscrasia.  If  relief  does  not  follow  ordinary  measures,  an  incision 
should  be  made  and  the  enlargement  dissected  out. 

In  certain  cases  in  which  adhesion  of  the  tendons  to  their  sheaths  and 
to  the  palmar  and  digital  fascia  occur  chiefly  as  a  result  of  i)enetrating 
wounds,  it  will — in  order  to  relieve  the  deformity — be  required  to  make 
an  open  dissection  and  divide  the  adhesions  in  plain  view.  Such  opera- 
tions can  be  done  with  impunity,  and  with  an  extraordinary  degree  of 
success,  if  the  strict  antiseptic  precautions  are  observed.  Esmarch's 
bandage  is  essential  to  the  operation,  and  cocaine  anaesthesia  I  have  fre- 
quently demonstrated  to  be  perfectly  satisfactory  in  these  procedures. 
The  wound  should  be  closed  at  once  with  fine  silk  sutures.  Catgut  is 
not  sufliciently  reliable  in  this  region.  The  danger  of  inflammation  and 
contractions  of  the  fascia  from  opening  into  the  hand  under  sublimate 


/^r,, 


Fig.  75]. — Gunshot-wouud  ol'  tlie  band.      Wound  of  entrance. 


irrigation  and  careful  antisepsis  are  exceedingly  remote.  Even  the  most 
extensive  injuries  of  the  hand  may  be  made  to  heal  with  as  little  deform- 
ity as  often  follows  a  simple  wound  in  which  inflammation  and  suppu- 


ADHESION    OF   THE   TENDONS. 


745 


ration  are  established.  Figs.  751  and  752  are  taken  from  a  hand  one  year 
after  the  receipt  of  a  gunsliot-vvoimd.  The  muzzle  of  the  piece  \vas  in 
contact  with  the  skin  at  the  time  of  the  exph)sion,  and  the  charge  of 


d 


d 


Flo.  752. — Wound  of  exit  of  the  ehar;re. 


small  shot  and  wadding  entered  at  the  palmar  aspect  of  the  little  finger, 
and  passed  out  through  the  metacarpal  bone  of  the  index-finger  and  to 
the  ulnar  side  of  tlie  thumb.  The  third  and  fourth  metacarpal  bones 
were  broken,  while  the  second  was  comminuted  and  almost  all  of  it  blown 
away.  The  flexor  tendons  and  fascia  of  the  palm  were  torn  and  divided. 
The  treatment  consisted  in  immersion  of  the  member  in  l-to-2000  subli- 
mate solution,  thorough  I'emoval  of  powder  and  all  foreign  matter,  repo- 
sition of  attached  fragments  of  bone  and  shreds  of  tendons,  fascia,  and 
muscle  in  as  near  their  normal  relation  as  possible,  and  applying  a  sub- 
limate-gauze dressing,  placing  the  hand  in  the  natural  position  and  hold- 
ing it  there  with  a  splint  and  roller.  In  this  case  motion  was  secured  in 
every  finger,  and  no  contractions  of  the  fascia  have  taken  place. 

AVhen  the  tendons  are  divided,  eitlier  in  the  forearm  near  the  wrist, 
or  in  the  jialm  or  along  the  fingers,  it 
is  essential  that  the  divided  ends  be 
stitched  together  with  silk  sutures.  Co- 
caine anaesthesia  and  Esmarch's  band- 
age should  be  employed. 

Deformities  of  the  hand  and  fingers 


Flo.  *l<-i%. — Defonnity  repultincr  from  exostosis. 
(After  Annaadulc  and  jS'oble  Smitli.) 


Fig. 


'54. — Deformity  resoltin?  from  chondroma 
of  the  phalanges. 


also  result  from  exostosis  and  new  formations  of  cartilage  in  the  digits 
(Figs.  753,  754).  Amputation  is  indicated  in  the  latter  condition,  while 
in  exostosis  relief  may  be  obtained  by  direct  incision  and  removal  of  the 
()ffendin<:  bone. 


CHAPTER  XXL 

TUMORS. 

The  word  tumor  (from  tumere,  to  swell)  was  formerly  applied  to  any 
abnormal  formation  or  ooUecticm  of  matter  Avitliin  the  body.  The  over- 
accumulation  of  fecal  matter  in  the  colon,  the  swelling  due  to  extravasa- 
tion of  blood,  or  to  the  retraction  of  a  muscle  after  rupture  of  its  tendon ; 
an  abscess,  a  retention-cyst,  a  hernia,  a  floating  or  displaced  kidney,  as 
well  as  all  the  recognized  non-inflammatorj^  neojalasms,  as  sarcoma,  fibro- 
ma, lipoma,  carcinoma,  etc.,  were  ranged  under  the  comprehensive  head- 
ing of  tumors. 

Of  late  years  the  application  of  the  term  has  been  more  restricted. 
A  tumor  is  now  deiined  to  be  a  circumscribed,  non-inJJammatorn  macs, 
composed  of  new-formed  elements  which,  having  their  type  in  the  nor- 
mal embryonic  or  adult  tissues,  are  dependent  upon  these  for  nutrition, 
and  yet  are  not  amenable  to  the  laws  reyulatiny  and  limitiny  the  derel- 
opment  of  the  normal  structures. 

Circumscribed,  because  a  general  or  wi  le-spread  liypertropliy  or  hy- 
perplasia does  not  convey  to  the  eye  or  touch  the  idea  of  a  swelling  or 
tumor.  The  accumulation  of  fat  in  obesity  can  not  be  called  a  tumor, 
yet  the  fat  so  deposited  over  a  wide  area  differs  in  no  essential  particular 
from  that  which  forms  a  lipoma. 

Non-inflammatory,  for  the  reason  that  this  most  clearly  separates 
true  neojilasms  from  the  cell-proliferation  of  the  ordinary  inflammatory 
process,  with  its  characteristic  heat,  pain,  and  redness,  as  well  as  swell- 
ing. 

New  formations  in  this,  that  although  the  law  estaldished  by  Johan- 
nes Miiller — that  the  elements  of  all  tumors,  no  matter  how  changed  from 
the  normal,  spring  from  and  have  their  types  in  the  normal  tissues  of 
embryonic  or  adult  life — stands  unquestioned,  yet  these  elements,  in 
their  changed  conditions,  tend  to  persist  or  to  grow  indefinitely,  in  utter 
disregard  of  the  laws  of  limitation  in  the  development  of  normal  tissues. 

The  efforts  at  classification  of  tumors  upon  a  histological  basis  have 
not  been  generally  satisfactory.  Virchow,  Foerster,  Cornil  and  Ranvier, 
and  other  pathologists,  with  the  same  end  in  view,  have  arrived  at  con- 
clusions scarcely  reconcilable.  A  discussion  fif  these  various  classifica- 
tions belongs  more  properly  to  special  works  on  pathology.  Clinically, 
they  admit  of  division  into  two  heads — the  malignant  and  non-malig- 
nant. 


CARCINOMA. 


747 


Malignancy  in  a  tumor  means  its  tendency  to  become  multiple  by 
metastasis  ;  the  tendency  of  the  elements  of  which  it  is  composed  to 
travel  along  the  lymj)h-  ov  blood-channels,  and,  thus  disseminated,  to  re- 
produce the  parent  tumor  ;  or  its  tendency  to  invade  and  destroy  the  tis- 
sues in  its  vicinity,  and  to  recur  in  loco  after  extirpation. 

Strictly  speaking,  the  tendency  of  a  neoi)Iasm  to  induce  death  has 
nothing  to  do  with  the  question  of  its  malignant  character,  for  certain 
tumors,  as  fil)ro-myomata  of  the  uterus  and  simple  ovarian  cysts,  tend 
to  produce  death  as  well  as  carcinomata  and  sarcomata. 

The  malignant  neoplasms  are  grouped  under  two  headings — carcino- 
ma and  sarcoma. 

The  non-malignant  are  as  follows  :  lipoma^  fibroma,  myxoma,  oste- 
oma, enchondromct,  angioma,  neuroma,  myoma,  adenomci,  papilloma, 
and  lymplioma. 

Carcinoma. — A  cancer  may  be  defined  to  be  a  tumor,  composed  of 
embryonic  cell-elements  of  varying  shape  and  proportions,  collected  in 
groups,  wdiich  groups  or  clusters  are  partially  separated  by  a  well-defined 
stroma,. 

While  the  elements  of  the  carcinomata  do  not  always  differ  so  widely 
from  those  of  the  sarcomata  (especially  the  more  embryonic  cells  of  this 
last  neoplasm\  the  alveolar  structure  of  the  stroma  of  cancer  will  always 
render  it  easy  of  recognition. 


Fia.  755. — Development  of  carcinoma.     »,  Bundles  of  fibrous  tissue  containinz  occasional  connective-tissue 
corpuscles,    a,  Cancer-cells  in  groups  or  rows  between  the  stroma.     (Atler  Cornil  and  Ranvier.) 


Cancer-cells  vary  greatly  in  shape  and  dimensions,  being  round,  flat, 
ovoid,  fusiform,  polygonal,  and  measuring  from  -^^  to  -5-3^  and  ^-^  inch 
in  diameter.     Eiich  cell  may  contain  one  or  many  nuclei.     The  nucleus 


748 


A  TEXT-BOOK   ON   SURGERY. 


Fio.  756.— Stroma  of  cancer  from  which  the 
cell-elements  liiive  bccu  removed.  (After 
Cornil  and  Kauvier.) 


is  often  of  large  size,  at  times  occupying  the  greater  portion  of  the  cell- 
space.  The  nucleoli  are  especially  ])roiiiineut.  The  cell-elements  of  car- 
cinoma are  c(mtained  within  the  alveoli,  and  float  in  or  are  in  contact 
with  a  juice  of  varying  quantity  and  consistence. 

.    The  walls  of  the  alveoli  are  comi)Osed  of   a  filjrillated   structure  of 
modilied  connective  tissue.     In  old  tumors  the  libei's  of  the  stroma  are 

closely  packed  together,  while  in  more 
recent  neoplasms  connective-tissue  cor- 
puscles are  frequently  observed  be- 
tween the  clusters  of  cells  (Fig.  755). 
The  alveolar  arrangement  of  the  stroma 
is  well  shown  in  Fig.  756,,  in  which  the 
cancer-cells  have  been  removed. 

The  alveoli  are  not  isolated  cavi- 
ties, but  communicate  more  or  less 
freely.  In  the  connective-tissue  walls 
of  the  alveoli  the  blood-vessels  and 
lymph-channels  are  lodged.  In  the 
development  of  a  carcinoma  the  pro- 
liferation among  the  cells  proper  of 
the  neoplasm  excites  a  similar  condi- 
tion in  the  connective-tissue  cells  of 
the  neighboring  and  involved  tissues, 
and,  coincident  with  the  multiplica- 
tion of  the  cancer-elements,  the  connective-tissue  elements  are  developed. 
In  this  way  the  stroma  is  formed  around  and  among  the  cancer-cells, 
and  in  rare  instances  this  proliferation  is  so  rapid  that  clusters  of  adipose 
cells  are  caught  within  the  neoplasm  and  remain  as  such  in  the  process 
of  growth  in  the  tumor. 

Carcinomata  spread  by  direct  invasion  of  contiguous  tissues,  and 
along  the  route  of  the  lymph-channels. 

It  is  not  uncommon  (as  established  by  Cornil  and  Ranvier)  for  indu- 
ration and  hypertrophy  of  the  ganglia  of  the  nearest  lymph-plexus  to 
occur  before  metastasis  has  taken  place,  a  fact  of  great  interest  to  the 
surgeon.  This  early  glandular  hyperplasia  is  due  to  the  irritation  caused 
by  the  neoplasm,  and  though  less  acute  is  not  unlike  the  adenitis  of  an 
ordinary  inflammatory  jjrocess. 

Three  chief  varieties  of  cancer  are  recognized — the  scirrhus,  encepJia- 
loid,  and  mucoid  or  colloid.  Epithelioma  will  also  be  included  under 
this  heading. 

Scirrhus,  or  hard  cancer,  is  distinguished  by  the  greater  proportion 
and  thickness  of  the  stroma,  in  comparison  with  the  cell-elements.  Many 
of  the  cells  in  this  variety  of  neoplasm,  especially  those  more  deeply  situ- 
ated, undergo  extensive  granular  metamorjjhosis,  and  appear  as  granular 
corpuscles,  having  lost  all  the  characteristics  of  the  cancer- elements. 

Encephaloid,  soft,  or  medullary  cancer  is  rich  in  cells  and  cancer- 
juice,  while  the  stroma  is  very  thin.  It  is  more  vascular,  and  in  gross 
appearance  is  lilie  broken-up  brain-matter  ;  hence  the  name  encephaloid. 


CARCINOMA.  749 

Owing  to  the  embryonic  character  of  the  new-formed  blood-vessels  and 
tlie  lack  of  resistance  from  the  scantily  developed  stroma,  aueurismal 
dilatations  of  the  vessels  are  common,  and  rupture  frequently  occurs. 

Colloid  cancer  is  characterized  by  the  presence  within  the  alveoli  of  a 
fluid  rich  in  mucin,  which  substance  also  appears  in  all  the  foci  that  may 
be  developed  by  metastasis.  Many  of  the  cells  disappear,  and  those 
which  remain  are  unusually  large  and  swollen.  The  alveoli  are  also  dis- 
tended and  the  walls  more  translucent  than  in  scirrhus. 

The  changes  which  cancers  undergo  are  chiefly  granular  metamorpho- 
sis and  ulceration.  The  cells  of  the  deeper  portions  of  the  neoplasm,  de- 
prived of  sufficient  nourishment  by  reason  of  their  central  position,  break 
down  in  a  granular  detritus,  which  is  absorbed  and  carried  away  in  ])art 
by  the  blood-vessels,  but  chiefly  by  the  lymph-channels.  In  older  tumors 
this  gradual  loss  of  cellular  elements  is  followed  by  contraction  of  the 
stroma  and  sinking  in  or  retraction  of  the  integument.  Inflammation 
and  ulceration  of  a  cancer  may  result  from  direct  irritation  from  without, 
or  may  occur  as  a  result  of  the  growth  of  the  neoplasm,  which  thus  often 
cuts  ofl"  its  own  nutrition.  The  process  is  not  unlike  ulceration  in  the 
normal  tissues,  only  the  granulations  are  often  very  exuberant  and  the 
death  of  tissue  rapid.  All  forms  of  carcinoma  are  siibject  to  the  deposit 
of  pigment,  and  under  such  conditions  have  been  termed  tnelanotic 
cancer. 

Causes. — Cancer  is  a  disease  of  adult  and  of  late  adult  life.  Scirrhus, 
encephaloid,  or  colloid  cancer,  under  twenty  years  of  age,  is  exceedingly 
rare.  It  occurs  chiefly  in  the  period  of  life  between  thirty  and  sixty. 
Women  are  more  frequently  attacked  than  men.  The  influence  of  he- 
redity upon  the  production  of  carcinoma  is  believed  to  be  established, 
although  its  importance  has  been  greatly  overestimated.  Prolonged 
irritation  is  undoubtedly  the  chief  exciting  cause  of  the  development  of 
this  neoplasm.  In  evidence  of  this  conclusion  is  the  fact  that  those  por- 
tions of  the  body  which  are  subjected  to  the  greatest  amount  of  irrita- 
tion are  most  often  afl'ected.  The  mammary  gland,  pylorus,  rectum,  and 
uterus,  are  the  more  common  locations  of  cancer. 

Diagnosis. — Tlie  recognition  of  cancer  is  positive  only  by  microscop- 
ical examination,  and  depends  in  part  upon  the  peculiar  characters  of 
the  cells  already  noted,  but  chiefly  upon  the  appearance  of  the  stroma. 
Clinically,  the  diagnosis  will  depend  upon  the  age  of  tlie  patient,  the 
location  of  the  tumor,  its  consistence,  immobility,  and  the  condition  of 
the  lymphatic  glands  in  the  line  of  the  vessels  toward  the  center.  A 
tumor  occurring  between  the  ages  of  thirty  and  sixty,  of  a  mildly  jiain- 
ful  character,  the  pain  sharp  and  lancinating,  and  increased  when  Arm 
pressure  is  exercised  ;  steadily,  although  at  times  slowly,  enlai'ging, 
movable,  it  may  be,  beneath  the  skin  or  A\ithin  the  substance  of  the 
organ  or  part  in  which  it  is  located,  yet  not  freely  so,  should  be  looked 
upon  with  suspicion.  If  it  has  existed  for  several  months,  and  there  is 
retraction  of  the  integument  over  a  portion  of  the  mass,  together  with 
induration  of  the  nearest  lymphatic  glands,  the  diagnosis  of  cancer  is 
almost  positive.     As  between  the  three  different  forms  of  cancer,  it  may 


750  A  TEXT-BOOK   ON   SURGERY. 

be  said  that  scirrlui.s  is  nuicli  tin-  more  ('(tmnum,  is  slower  in  growth, 
and  harder  to  tlie  fee].  Colloid  is  also  liard,  and  grows  slowly,  and 
from  pali)ati()n  and  insjieotion  can  not  he  dillVrentiatcd  from  scinhus 
with  any  certainty.  It  is  comparatively  rare.  Enceiihaloid  is  a  soft, 
elastic  tumor,  not  always  of  uniform  consistence,  but  generally  of  smooth 
surface,  and  always  of  rapid  giowth.  Its  vascularity  is  therchn-e  much 
more  noticeable  than  that  of  either  of  the  other  varieties,  and  metastasis 
is  more  i-apid.  As  between  sarcoma,  the  chief  diagnostic  points  are  the 
age  of  the  patient,  sarconui  being  more  common  in  the  young,  cancer  in 
the  old  and  middle-aged  ;  the  lymphatics  are  not  involved  in  sarcoma, 
except  when  extensive  ulceration  and  septic  absoriDtion  occurs  ;  in  gen- 
eral, the  superficial  veins  of  sarcoma  are  more  dilated  and  perceptible, 
and  the  tumor  more  elastic. 

As  far  as  the  treatment  is  concerned,  the  differentiation  between  car- 
cinoma and  sarcoma  is  not  essential.  The  indication,  when  operative 
interference  is  at  all  justifiable,  is  extirpation  of  the  mass  by  a  dissection 
which  should  be  well  away  from  the  limits  of  the  neoplasm.  In  cancer 
the  neighboring  lymphatic  glands  should  be  extirpated  if  metastasis  has 
occurred,  while  in  sarcoma  this  is  not  indicated.  In  fact,  in  all  neoplasms 
not  positively  innocent,  removal  should  lie  made  imperative.  The  slight- 
est doubt  of  the  character  of  the  tumor  is  entitled  to  the  interpretation  of 
malignancy,  the  justification  of  this  conclusion  being  found  in  the  well- 
established  fact  that  an  innocent  neoplasm  may  become  malignant. 

The  excision  of  a  portion  of  a  tumor  for  microscopical  examination 
for  purposes  of  diagnosis  will  rarely  be  justifiable.  Any  irritation  of  the 
mass  is  reprehensible,  since  metastasis  is  more  apt  to  occur  under  such 
conditions. 

Epithelioma. — An  epifJielioma  may  be  defined  as  a  neoplasm,  the 
embrycmic  elements  of  which  assume,  in  a  varying  degree,  the  shape  and 
arrangement  of  the  normal  epithelium.  Developing  usually  in  the  skin 
or  mucous  membranes,  they  at  times  originate  in  tissues  remote  from 
them,  as  in  the  hemes. 

Malignant  epitheliomata  may  be  divided  into  two  classes:  1,  the  lob- 
ular ;  2,  the  tubular.  Tubular  epithelioma  may  consist  of  {a)  flat  or 
round  cells,  (h)  columnar  or  cylindrical  cells. 

The  first  variety  is  by  far  the  more  common,  and  of  greatest  clinical 
interest.  It  occurs  by  preference  upon  the  muco-cutaneous  surfaces,  as 
the  lips,  prepuce,  anus,  vulva,  etc.,  but  may  appear  either  upon  the  skin 
or  mucous  surfaces,  remote  from  any  line  of  union  of  these  coverings,  as 
the  tongue,  cheek,  face,  etc. 

Epithelioma  usually  begins  as  a  nodule  or  induration  of  small  size, 
slightly  reddened  at  its  margin,  the  center  of  which  very  early  in  its  his- 
tory breaks  down  into  a  dirty  ulcer  which,  when  kept  fairly  clean,  is 
reddish  in  color,  and,  when  not  cleansed,  is  covered  with  a  grayish  mass 
of  pus  and  broken-down  tissue,  either  solidified  into  a  crust  or  scab, 
or  in  a  softened  state.  The  margins  of  the  ulcer  are  sinuous,  hard,  and 
evei'ted.  It  may  limit  itself  to  a  small  area,  or  develop  steadily,  and 
sometimes  with  great  rapidity  until,  after  extensive  destruction  of  the 


EPITHELIOMA. 


751 


tissiies  in  its  neighborhood,  death  ensues  from  hismorrhage,  sepsis,  or 
metastasis.  Pain  is  always  a  symptom  of  this  disease.  Lymphatic  en- 
gorgement may  occur  in  the  first  few  weeks,  but  usually  from  four  to 
eiglit  months,  and  even  a  longer  time,  may  elaj^se. 

Examined  microscopically,  this  form  of  epithelioma  is  seen  to  be 
composed  of  flattened  cells,  containing  one  or  several  nuclei,  with  a  tend- 
ency on  the  part  of  the  elements  to  form 
themselves  in  concentric  layers  (Fig.  757). 
In  the  center  of  these  spheres  of  flattened 
epitbelia  are  frequently  seen  a  few  cells 
which  have  undergone  the  colloid  change. 
Farther  out  the  surrounding  cell-elements 
are  more  embryonic  in  character,  cylindri- 
cal, spherical,  or  polygonal  from  lateral 
compression,  the  mass  being  limited  ex- 
ternally by  a  stroma  of  connective  tissue, 
varying  in  quantity,  which  separates  one 
epithelial  nest  fi-om  the  others  composing 
the  entire  neoplasm.  In  the  process  of 
ulceration  an  epithelioma  is  surrounded 
by  a  zone  of  embryonic  tissue  du3  to  the 
cell-proliferation  of  the  inflammatory  pro- 
cess. 

Flat    or   Round,   and    Columnar    or 
Ci/lindr leal-Cell   Epithelioma.  — Tubular 
epitheliomata  are    somewhat   less   malig- 
nant than  the  lobular  or  bird's-nest  variety  just  described.     After  reach- 
ing a  certain  stage  in  their  development,  they  may  remain  stationary  ; 

but,  in  the  majority  of  instances,  the  tendency 
is  to  grow,  as  well  as  to  recur  after  removal. 
They  are  usually  situated  upon  the  skin,  where 
they  originate  in  the  sweat-glands  or  upon  the 
mucous  membranes,  where  they  spring  fram 
the  follicles  of  these  surfaces.  The  antrum 
maxillare  is  occasionally  the  seat  of  this  variety 
of  neoplasm. 

Microscopically,  the  flat-celled  epitheliomata 
are  composed  of  pavement  or  tesselated  cells, 
crowded  in  tubules  or  cylinders,  which  are  long, 
more  or  less  irregular  in  shajje,  at  times  anas- 
tomosing with  each  other,  and  are  held  togeth- 
er by  a  stroma  of  connective  tissue  (Fig.  7o8). 

The  general  shape  of  these  neoplasms  is 
oval  or  round.  They  grow  more  slowly  than 
the  preceding  variety. 

Columnar-celled  cylindrical  epithelioma  is 
met  with  in  the  deeper  organs,  as  the  aliment- 
ary canal  and  other  abdominal  viscera,  uterus, 


Fig.  757. — Lobular  or  spberic.il  epitlieli- 
oma,  250  diameters.  (After  Coruil 
and  Eanvier.) 


Fm.    758, 


Tubular  epithelioma, 
ff,  Tul^ulcs  or  cylintfcTs  out  ob- 
liquely. ^,  Connective-tissue 
stroma.  (^After  Oornil  and 
Kanvier. ) 


752 


A  TEXT-HOOK   ON   SURGERY. 


ovaries,  etc.  It  differs  from  the  ])recedin^-  in  tlie  shape  of  the  eintlielia 
which  line  the  tubules.  The  cells  are  col un)iiar,  set  on  end,  contain  one 
or  more  nuclei,  and  may  exist  in  a  siu<(le  layer  pv  as  several  rows  of 
cells  piled  on  each  other.  The  framework  or  stroma  is  composed  of 
C(mnective  tissue,  which  may  have  a  iibrillated  arrangement,  or  it  may 
remain  in  an  embryonic  conditit)n  (Fig.  759). 

The  prognosis  of  these  tumors  is  unfavorable.  They  are  rarely  rec- 
ognized at  a  period  early  enough  in  theu-  history  to  allow  of  a  thorough 
removal.  Those  of  tlie  os  and  cervix  uteri,  ovaries,  rectum,  and  nose  are 
most  easily  removed. 


l-'iu.  V59. — Tubular  epitlielioina  with  cylindrical  ele- 
ments. «.  Tuliule  cut  acMss.  /',  'Tubule  cut  in 
its  Ions  axis,  c^  Cylindrical  cpithclia.  (After 
Cornil  and  Kanvicr.j 


Fio.  TOO.— Reticular  structure  of  a  lymphatic  in- 
testinal fnllicie.  a  It,  Capillary  vessels  with 
nuclei  in  their  walls.  {',  Meshes  of  the  retic- 
ular structure  containing  lymphatic  corpus- 
cles.    (After  Frey.) 


LympTiadcnoma. — This  variety  of  neoplasm  is  entitled  to  be  classed 
with  the  malignant  tumors.  It  consists  of  new-formed  lymphatic  gland- 
tissue,  and  may  occur  in  pre-existing  glands  or  in  any  of  the  tissues  of 
the  body.  The  liver,  spleen,  and  kidneys,  the  testicle,  the  alimentary 
canal,  the  bones  and  integument,  may  all  be  the  seat  of  these  new  forma- 
tions. Coincident  with  the  development  of  these  neoplasms,  the  jn-o- 
portion  of  white  blood-corpuscles  in  the  volume  of  blood  is  enormoxisly 
increased,  until  death  ensues  from  leucocytluemia.  These  tumors  may 
be  of  any  size,  from  a  millet-seed  up  to  several  inches  in  diameter,  are 
soft  to  the  touch,  and  usually  not  well  defined.  They  can  not  be  diag- 
nosticated from  other  gland-tissues  unless  examined  microscoiiically, 
when  they  are  seen  to  consist  of  a  connective-tissue  framework  or  reticu- 
lum, along  the  hbrilhe  of  which  run  the  capillaries,  and  in  the  meshes  of 
the  reticulum  the  lymph-corpuscles  are  situated  (Fig.  700). 

The  prognosis  is  grave,  and  the  condition  does  not  justify  surgical  in- 
terference. 

Sarcomata. — A  sarcoma  is  a  tumor  the  elements  of  which  have  their 
type  in  the  normal  connective  tissues.  The  cells  of  a  sarc(mia  may  be 
purely  embryonic,  or  may,  in  a  certain  sense,  resemble  the  more  devel- 
oped elements.  They  are,  however,  not  ca])able  of  organization  into  a 
permanent  tissue. 

Classified  according  to  the  shape  and  size  of  the  cell-elements  which 


SARCOMATA.  753 

preponderate  in  their  composition,  they  are  called — 1,  round;  2,  spindle; 
3,  giant-cell  sarcoma. 

The  cell-elements  of  the  sarcomata  not  only  vary  in  size  and  shape, 
bxit  in  the  number  of  their  nuclei,  of  which  there  may  be  from  one  to 
thirty  or  more.  In  the  more  fully  developed  or  spindle-celled  neoplasm, 
the  elements  are  arranged  in  bundles  which  run  in  all  directions.  These 
tumors  possess  little  or  no  intercellular  substance,  the  elements  resting 
in  contact  or  separated  by  the  blood-vessels  which  freely  permeate  them. 
The  richness  of  the  blood-supply  and  the  jn'oportion  of  the  tumor  occu- 
pied by  these  channels  are  well 
shown  in  Fig.  761. 

The  size  and  number  of  the 
blood-channels  depend  upon  the 
structure  of  the  tumor,  the  round- 
cell  sarcoma  being  most  vascular, 
while  the  vessels  are  less  numerous 
and  of  smaller  caliber  in  the  spindle- 
cell  variety. 

The  intercellular  sid)stance  also 
varies  in  quantity,  being  scarcely 
perceptible  in  the  round-cell  tumor, 
and  more  distinct  in  the  spindle  or 

„       .„  .    ^  T-  j»    ^1  Fig.  761. — Inicction  of  tlic  vascular  network  of  an 

lUSltorm    variety.       In    some    OI    the  osteo-sareoma.     (After  Billroth.) 

sarcomata  normal  connective-tissue 

fibers  may  exist,  and  these  are  believed  to  have  been  (laught  in  the  de- 
velopment of  the  neoplasm. 

The  sarcomata  in  general  develop  with  great  rapidity,  and  tend  to  in- 
vade or  infiltrate  the  structures  in  their  immediate  neighborhood.  In 
this  the  different  forms  of  tumor  also  differ.  The  round-celled  neoj)lasm 
grows  more  rapidly  than  the  others,  and  is  more  apt  to  invade  the  sur- 
rounding tissues  than  the  fusiform-cell  variety.  It  is  not  the  rule  for 
these  neoplasms  to  become  encapsuled,  although  this  may  occur  in  the 
spindle-  or  giant-cell  variety. 

The  three  varieties  of  cells  may  exist  in  the  same  tumor.  According 
to  Cornil  and  Ranvier,  a  careful  search  will  reveal  the  pre.sence  of  giant 
cells  in  varying  numbers  in  almost  all  sarcomata. 

The  retrogressive  changes  which  the.se  tumors  undergo  are  fatty  and 
calcareous  degeneration.  The  deeper  cells  of  tumors  of  considerable  size 
—in  other  words,  those  farthest  removed  from  the  supply  of  nutrition — 
very  commonly  undergo  the  fatty  or  granular  metamorphosis.  Not  in- 
frequently this  granular  metamorjjhosis  proceeds  so  rapidly  that  the 
blood-vessels  of  the  tumor  become  occluded  with  the  fatty  detritus  (gran- 
ular infarction).  In  this  way  the  nutrition  in  certain  portions  of  the 
growth  is  interfered  with,  increasing  the  area  of  fatty  metamorphosis,  or 
inducing  gangrene  from  a  sudden  arrest  of  the  blood-current. 

Calcareous  degeneration  occurs  in  certain  of  the  sarcomata  irresjiect- 
ive  of  their  being  situated  in  the  neighborhood  of  bone.  Pigmentation 
occasionally  occurs,  and  this  form  is  at  times  separately  classified  as  me- 

48 


754  A   TEXT-BOOK   ON   SURGERY. 

lanotic  sarcoma.  It  is  apt  to  take  i)lace  in  the  small,  round-cell  tumors. 
Acute  inflammation  in  a  sarcoma  is  almost  always  followed  by  the  pro- 
liferation of  an  exuberant  ,iinuiulnti(m-tissue,  with  more  or  less  extensive 
gangrene  and  death  of  the  mass.  Excessive  ami  at  times  fatal  luemor- 
rhage  may  occur  in  the  process  of  sloughing. 

A  common  accident  in  the  evolution  of  a  sarcoma  is  the  extmvasation 
of  blood  from  rupture  of  the  walls  of  the  new-formed  vessels.  Such  is 
the  crude  condition  of  these  tumors  that  even  the  cells  which  compose 
the  vessels  are  eml)ryonic,  and  readily  give  way,  allowing  the  escape 
of  blood  among-  the  cell-elements  and  intercellular  spaces.  The  moi-e 
nearly  the  development  of  the  cells  approaches  a  normal  tissue,  the 
less  probability  there  is  of  extravasation.  The  blood  thus  escaped 
may  be  absorbed  or  become  encai^suled  by  pressure  upon  the  cells  near 
the  point  of  rupture  and  become  converted  into  a  blood-cyst. 

Mucoid  degeneration  is  also  occasionally  met  with 
in  these  neoplasms.     The  cells  of  certain  portions  of 
the  tumor  disappear,  leaving  cysts  or  alveoli  varying 
in  size  from  the  smallest  iip  to  as  large  as  two  or 
three  inches  in  diameter  in  large  tumors.     The  cysts 
are  occupied  by  an  amber-colored  or  reddish-brown 
fluid,  which,  examined  with  the  microscope,  demon- 
strates the   presence  of  blood-corpuscles  in  various 
conditions   of  degeneration.      Chemically,    the  fluid 
coma!'"'(AVtcr'^Gn!en.)'^      yields  fiiucin.     The  name  alveolar  sarcoma  (Fig.  762) 
has  been  given  to  this  form  of  tumor. 
Clinical  Featxre-s. — Sarcomata  may  be  met  with  in  all  conditions  and 
at  any  period  of  life.     Comparatively  speaking,  they  are  rare  in  old  age, 
occurring  chiefly  in  clnldren  and  adults  under  thirty.     Occasionally  they 
are  congenital.     Both  sexes  are  equally  liable  to  be  atta(;ked.     They  are, 
as  a  rule,  idiopathic  in  origin,  in  rare  cases  being  due  to,  or  at  least  fol- 
lowing, an  injury  to  the  part  involved  in  the  neoplasm.     Sarcomata  are 
among  the  most  malignant  new  formatitms,  not  only  recurring  in.  loco 
after  removal,  biit  tending  to  be  disseminated  by  the  blood-vessels.     Un- 
like the  carcinomata,  they  have  no  lympli-channels.  and  metastasis  must 
occur  by  the  blood-vessels  which  enjoy  free  anastomoses  with  the  caverns 
and  sinuses  of  the  neoplasms. 

The  degree  of  malignancy  of  a  sarcoma  is,  in  general,  in  proportion 
to  the  embryonic  character  of  the  elements  of  which  it  is  composed. 
Thus,  the  round-celled  tumors  of  rapid  development  are  most  malignant, 
the  spindle-celled  next,  the  giant-celled  last  in  this  order. 

As  to  location,  no  tissue  is  exempt.  They  are  frequently  met  with  in 
the  skin  and  subcutaneous  tissues  (Fig.  763);  also  the  osseous  tissues, 
especially  the  long  bones,  furnish  a  favorite  seat  for  them.  Those  devel- 
oi)ing  from  within  are  chiefly  the  myeloid  or  giant-celled  variety  ;  those 
of  periosteal  (uigin  are  round-  or  spindle-celled. 

Sarcoma  of  the  bones,  according  to  Prof.  S.  W.  Gross,  who  has  writ- 
ten a  most  exhaustive  paper  upon  this  subject,  is  exceedingly  malignant, 
being  only  second  to  cancer  of  the  soft  tissues. 


SPECIAL  FORMS  OF  SARCOMA. 


755 


Fig.  763. — Sarcoma  of  the  scalp  and  mck. 


From  the  foregoing  it  is  evident  tliat  the  prognosis  in  any  of  the  vari- 
eties of  sarcoma  is  unfavorable.     The  gravity  is  increased  with  the  dura- 
tion of  the  tumor,  its  location  near  the 
trunk,    and   with   the  rapidity   of   its 
growth. 

The  round-celled,  especially  those 
which  have  undergone  the  melanotic, 
mucoid,  or  alveolar  change,  are  most 
dangerous  ;  next,  the  spindle-celled, 
and,  lastly,  the  myeloid  or  giant-celled 
variety. 

The  Treatment. — Situated  superfi- 
cially, or  in  the  soft  parts,  they  should 
be  excised  as  soon  as  observed.  The 
incision  should  always  be  wide  of  the 
suspected  limit,  and  the  skin  and  all 
the  tissues  should  be  removed  well  be- 
yond the  tumor.  When  a  bone  is  the 
seat  of  the  new  formation,  no  effort  should  be  made  to  preserve  the  peri- 
osteum. The  bone  should  be  divided  as  far  beyond  the  lesion  as  may  be 
deemed  consistent  with  the  safety  of  the  patient  and  the  preservation  of 
the  function  of  the  part  involved. 

When  a  sarcoma  is  developed  upon  an  extremity,  if  it  be  small  or  of 
very  recent  date,  a  wide  extirpation  should  be  undertaken  ;  but,  if  there 
is  at  any  time  thereafter  an  indication  of  recurrence,  amputation  should 
be  con.sidered. 

Sarcoma  of  the  bones  of  the  extremity  calls  for  immediate  amputa- 
tion.    If  the  tibia  is  involved,  disarticulation  at  the  knee  is  indicated. 
If   the  neoplasm  is  located  in  the  femur  below  the  middle,  the  bone 
should  be  removed  at  the  hip.     If  the  soft  parts  are  not  involved,  a  long 
flap  shf)uld  be  made,  and  the  femoral  vessels  divided  as 
low  down  as  possible. 

Special  Forms  of  Sarcoma — Round-Cell  Variety. — 
The  cells  are  analogous  to  the  embryonic  elements  of  the 
ordinary  inflammatory  process  from  which  they  can  not 
be  distinguished.  They  possess  one  or  more  nuclei  and 
nucleoli,  and  are  spherical,  or  with  slightly  irregular  out- 
lines from  reciprocal  pressure.  The  intercellular  sub- 
stance is  homogeneous,  and  either  very  scanty  or  entirely 
absent  (Fig.  704).  The  vessels  and  blood-channels  have 
been  described.  This  variety  of  sarcoma  occurs  every- 
where. In  the  neuroglia  of  the  brain  and  the  neurilemma  elsewhere  it 
has  been  called  neurosarcoma  or  glioma. 

Splndle-Cell  Sarcoma. — The  cells  of  this  variety  are  elongated  or 
fusiform  in  shape,  containing  usually  one,  at  times  several,  nuclei.  The 
ends  of  the  spindle  may  be  single  or  bifurcated  (Fig.  765).     The  cells 


I**.,, 


Fig.  V(i4. — Round- 
cell  sarcoma, 
(After  Green.) 


varv  in  size  from  ^, 


TJolf 


tOrffTT 


of  an  inch  in  diameter,  and  are  arranged  in 


bundles  luuning  in  various  directions  (Fig.  7GG). 


756 


A  TEXT-BOOK   OX   SURGERY. 


Clinically,  this  is  the  most  coiniinni  form  of  sarcoma.  They  are  slower 
in  development,  firmer  to  the  feel,  and  less  vascular,  and  of  smaller 
dimensions  th:in  the  preceding  variety.     As  stated,  they  are  somewhat 


Fio.  765.— Multipolar  cells  of  a  sarcoma.     (After  Cornil  and  Kanvier.) 

less  malignant.  They  may,  in  rare  instances,  be  encapsuled,  although 
the  rule  is  to  invade  the  surrounding  tissues.  The  favorite  location  for 
their  development  is  the  periosteum  and  in  the  substance  of  the  bones. 


Spindle-tell  sarcoma.     (After  Virchow.) 


They  attack  the  glandular  structures,  not  infrequently  affecting  the 
breast.  WhUe  developing  here,  the  increased  vascularity  of  the  neo- 
plasms induces  hyper;emia  of  the  glandular  ap])aratus  of  the  breast  with 
consequent  proliferation  of  the  epithelia,  a  condition  which  has  been 
termed  by  Billroth  adeno-sarcoma. 

Giant-Cell  Saj-coma. — The  cells  of  this  neoplasm  are  of  all  sizes  and 
shapes:  spherical,  fusiform,  and  irregularly  oval,  having  at  times  one, 
at  others  thirty  or  more  nuclei  (Fig.  767).  They  clo.sely  resemble  the 
cells  of  the  normal  marrow  of  foetal  bones.  Clinically,  this  form  of  sar- 
coma is  met  with  usually  in  the  bones,  especially  in  the  lower  jaw  and 


NON-MALIGNANT   NEOPLASMS. 


757 


the  long  bones.  It  may  develop  to  an  enormous  size,  remaining  practi- 
cally confined  to  a  single  bone ;  less  frequently  spreading  to  the  sur- 
rounding soft  parts.  Bones  so  affected  at  times  become  friable,  being 
readily  fractured  from  the  body-weight,  or  yield  a  crackling  sound  upon 
palpation.* 


Fig.  767. — Giant-oell  sarcoma.    From  a  sarcoma  of  bone.    (After  Ordonez.) 


NON-MALIGNANT  NEOPLASMS. 

The  non-malignant  epifheliomata  are  the  dry,  pavement,  or  pearl- 
like epithelioma,  papilloma,  the  adenoma,  and  the  cystic  tumors. 

The  pearl  epithelioma  is  of  rare  occurrence.  Microscopically,  it  is 
found  to  be  closely  akin  to  the  bird's-nest  tumors,  which  are  classed 
with  the  malignant  growths.  The  cells  of  the  non-malignant  and  rare 
neoplasm  are,  however,  fiat,  and  collected  in  little  dry,  pearl-like  bodies, 
gathered  in  clusters,  and  held  together,  or  surrounded  by  a  connective- 
tissue  stroma.  Occasionally,  cholesterine  crystals  are  seen  in  these 
bodies,  and  this  fact  induced  ^luller  to  name  this  form  of  neoplasm 
"  cJiole  steal  oma.''' 

The  proper  treatment  is  removal  with  the  knife. 

PapiUoma. — A  papilloma  is  a  neoplasm,  in  structure  not  Tinlike  the 
normal  papilhc  of  the  skin  and  mucous  membranes.     Each  papilla  pos- 

*  For  a  coDsideration  of  the  varions  mixed  varieties  of  sarcoma,  viz.,  osteoid,  neiiro-  and 
lipo-sarcomata,  ansiolitbic  sarcoma,  etc.,  the  student  is  referred  to  the  text-books  on  pathology, 
and  especially  to  the  escellcnt  work  of  Cornil  and  Ranvier,  which  the  author  has  drawn  from 
extensively. 


758  A  TEXT-BOOK   ON  SURGERY. 

sesses  a  connective-tissue  framework  which  supports  one  or  more  new- 
formed  vascular  loops,  and  the  whole  is  covered  in  witli  one  or  several 
layers  of  epithelia. 

They  may  be  met  with  npon  the  cutaneous,  mucous,  or  serous  sur- 
faces. 

The  most  frecjuent  form  of  papilloma  is  the  ordinary  "wart."  The 
hard  or  cutaneous  wart  is  often  seen  upon  the  hands  ;  the  soft  or  mu- 
cous wart  is  frequently  met  with  npon  the  prepuce,  vulvn,  and  anal 
mart^ins.     Corns  are  also  classified  as  papillomata. 

Mucous  warts  grow  more  exuberantly  than  those  of  the  skin.  Upon 
the  prepuce,  where  they  are  kept  moist  and  are  subjected  to  irritnting 
secretions  and  to  friction,  they  fonn  at  times  enormous  masses.  Il;pm- 
orrhage  is  a  common  accident,  and  sloughing,  with  the  emission  of  a 
most  olfen.sive  odor,  is  the  rule  in  these  larger  neoplasms. 

Essentially  benign  painllomnta  may,  by  long-continued  irritntion,  be 
converted  into,  or  replaced  by,  an  emlnyonic  neoplasm  of  a  malignant 
type. 

Treatment. — The  indication  is  to  destroy  them  at  once.  Tlie  best 
method  to  pursue  is  to  grasp  them  with  forceps,  clip  them  off  with  scis- 
sors close  to  the  attached  margin,  and  apply  nitric  acid  to  the  bleeding 
base  of  the  neoplasm.  Anaesthesia  is  obtained  by  moistening  them  for 
several  minutes  with  a  4-per-cent  solution  of  cocaine  hydrocldorate.  The 
nitric  acid  leaves  a  yellow  stain,  which  is  objectionable  when  the  growth 
is  situated  npon  an  exposed  surface. 

Adenoma. — Adenomata  are  neoplasms  the  structure  of  which  is  analo- 
gous to  gland-tissue.  Following  this  analogy,  they  are  of  the  racemose 
and  tubular  varieties.     The  racemose  adenomata  are  extremely  rare. 


V  [,^'i-?' 


Fio.  76S. — Nasal  polypus,    a,  Pavement  epitheli.i,  of  which  the  deeper  layers,  d.  are  cylinilrical,  and  are 
arranged  along  tfie  edges  of  the  papilla',  b.    A  vessel  is  shown  at  b.   "(After  Coruil  and  Kanviir.) 

They  are  composed  of  collections  of  acini  held  together  by  a  varying 
quantity  of  connective  tissue,  and  lined  with  epithelium.  They  may 
develop  in  all  parts  of  the  economy  where  the  racemose  glands  are 


CYSTS.  ,  759 

found.  A  favorite  location  is  the  mammary  gland,  occasionally  in  the 
parotid,  the  lachrymal  gland,  and  the  roof  of  the  mouth.  They  are 
slow  in  growth,  are  sj)herical  in  shape,  and  are  freely  movable  in  the 
structure  in  wliich  they  develop. 

Tubular  adenoma  is  more  frequently  observed  than  the  racemose  va- 
riety. The  tubules  are  in  some  cases  separated  by  a  laj'er  of  new-formed 
connective  tissue,  while  in  others  there  is  no  perceptible  intertubular 
stroma.  The  tul)ules  may  be  single,  but  are  more  frequently  bifurcated, 
and,  as  in  the  normal  glands,  commence  in  blind  extremities  and  open 
upon  the  mucous  surface.  They  are  lined  with  one  or  more  layers 
of  glandular  epithelium.  These  tumors  are  seen  in  the  rectum  and 
colon,  in  the  uterus,  especially  the  cervix,  and  occasionally  in  the  nose 
(Fig.  768). 

They  are  spherical  or  pyriform  masses,  covered  with  mucous  epithe- 
lium as  long  as  they  are  contained  within  the  cavities ;  but  when,  by 
reason  of  excessive  growth,  they  are  exposed  to  the  air,  the  covering  be- 
comes hard  and  smooth,  like  the  epidermis. 

Cysts. — A  cyst  is  a  tumor  composed  of  a  limiting  membrane  or  cap- 
sule of  connective  tissue,  lined  by  epithelium  and  hlled  with  fluid  or 
semi-fluid  contents.  The  contained  matter  may  be  mucoid  or  colloid 
material,  or  sebaceous  matter  and  epithelial  cells  in  various  conditions  of 
degeneration. 

Sebaceous  cysts  occur  upon  all  portions  of  the  external  surface,  and 
in  rare  instances  develop  in  the  deeper  tissues. 

The  external  sebaceous  tumors  are  seen  very  frequently  upon  the 
face  and  scalp,  and  vary  in  size,  measuring  at  times  an  inch  or  more  in 
diameter.  They  are  spherical  or  flattened  tumors,  soft  and  elastic  to  the 
touch,  and  freely  movable  ui)on  the  subcutaneous  tissues. 

The  contents  may  be  a  white,  cheesy  matter  or  more  fluid,  and  of  an 
amber  or  brown  color.  Examined  microscopically,  it  is  seen  to  be  com- 
posed of  epithelial  cells  which  have  undergone  a  more  or  less  complete 
granular  metamorphosis,  loose  granules,  compound  granialar  corpuscles, 
cholesterine  crystals,  rudimentary  hairs,  etc.  The  wall  of  the  cyst  varies 
in  thickness,  being  at  times  very  thin  and  closely  adherent  to  the  sur- 
rounding structures,  and  at  others  thick  and  easily  detached.  Those 
ixpon  the  hairy  scalp,  commonly  known  as  "we«s,"  are  usually  filled 
with  an  amber-colored,  jelly-like  mass,  which  escapes  upon  section  or 
puncture  of  the  cyst.  Upon  the  face,  or  other  cutaneoiis  surface,  the 
contents  are  apt  to  be  cheesy  in  character. 

They  are  caused  by  cell-proliferation  and  the  accumulation  within  the 
hair-follicle  and  communicating  sebaceous  gland  of  its  normal  secretion, 
which  can  not  escape,  owing  to  the  partial  or  complete  occlusion  of  the 
excretory  duct.  Cutaneous  cysts,  from  direct  violence,  and  often  with- 
out any  appreciable  cause,  may  inflame  and  supjiurate. 

Dermoid  cysts  are  closely  analogous  to  the  preceding,  although  situ- 
ated in  the  deeper  structures.  They  consist  of  a  limiting  membrane,  and 
liquid  and  solid  ccmtents.  In  addition  to  the  changed  ei)ithelial  cells  and 
granular  matter,  these  tumors  often  contain  tufts  of  hair,  rudimentary 


760  A   TEX  r-BOOK   ON   SURGERY. 

teeth,  etc.  They  occupy  by  preference  tlic  ovary,  but  are  met  with  in 
all  parts  of  the  body. 

Mucous  cj/sts  are  usually  seen  upon  the  lips,  buccal  cavity,  vulva, 
and  anus.  They  may  occur  in  any  poi-tion  of  the  alimentary  or  res])ira- 
tory  passages,  or  in  any  of  the  cavities  lined  by  mucous  membrane.  The 
wall  is  thin,  lined  with  epithelium,  aiul  adherent  to  the  surroundintc 
structures.  The  contents  are  a  viscid  mucus,  resembling  the  white  of  an 
e^s:.  The  cause  of  the  tumor  is  obstruction  of  the  normal  excretory 
duct.  The  character  of  the  tumor  may  be  suspected  from  the  location 
and  the  spherical  shape.  A  slight  puncture,  with  compression,  will  re- 
veal the  miicous  character  of  the  contents. 

SeroHS  C;/sfs. — Cysts  of  the  smaller  serous  cavities  may  result  from 
hypersecretion  of  the  normal  fluid  by  the  epitlielia  lining  the  serous 
membrane,  in  which  the  excess  is  not  reabsorbed.  The  swellings  often 
observed  upon  the  back  of  the  wrist  and  hand,  and  sometimes  upon  the 
dorsal  aspect  of  the  foot,  are  typical  serous  cysts,  and  result  from  liyper- 
distention  of  normal  serous  bursae. 

Lipoma. — A  fatty  tumor  is  a  circumscribed  collection  of  adipose  tis- 
sue growing  independently  of  tlie  other  tissues.  Lipomata  usually  de- 
velop in  the  subcutaneous  cellular  tissue,  and  are  frequently  met  with 
about  the  back  of  the  neck  and  shoulders.  From  this  location  they  occa- 
sionally are  carried  by  gravity  toward  the  sacrum,  slipi)ing  downward 
between  the  integument  and  deep  fascia.  Situated  superficially,  they 
grow  to  be  irregular  and  spherical  or  pyriform  tumoi's  of  varying  size  ; 
are  usually  single,  but  may  be  multiple.  Less  often  they  are  met  v.ith 
in  the  glands,  muscle.s,  bones,  and  in  the  abdominal  viscera. 

Microscopically,  they  are  composed  of  vesicles  filled  with  oil  or  fat. 
The  vesicles  are  connective-tissue  corpuscles,  the  nuclei  of  which  are  dis- 
placed to  the  periphery  and  compressed  against  the  investing  membrane 
of  the  vesicle.  These  vesicles  are  held  together  in  clusters  of  various 
size  by  a  stroma  of  tilirous  tissue,  in  the  meshes  of  which  the  blood-vessels 
run.     The  whole  tumor  is  in  turn  encapsuled. 

Various  names  have  been  given  to  certain  complex  fatty  tumors ; 
when  the  inter- vesicular  substance  is  myxomatou.s,  7???/.ro-Z^7>o/fta/  when 
the  connective  tissue  is  excessive,  fibro-llpoma  ;  in  bone,  osteo-lipoma ; 
when  very  vascular,  angelo-lipoma,  etc. 

Lipomata  may  undergo  granular  and  calcareous  metamorphosis,  and 
may  also  become  intiamed  and  break  down  as  a  very  olfensive  and  slough- 
ing mass.  They  are  altogether  benign,  and  can  only  cause  death  by 
ulceration,  sepsis,  and  haemorrhage,  or  by  pressure  upon  important  or- 
gans. 

The  diagnosis  depends  upon  the  soft,  uneven  feel  and  the  mobility  of 
the  mass.  It  is  only  to  be  differentiated  from  old  abscesses  or  cystic  tu- 
mors. If  the  history  does  not  point  to  the  diagnosis,  the  aspirator-needle 
will  be  of  service. 

The  ti-eatment  is  removal  with  the  knife.  The  incision  may  be  straight 
for  a  small  tumor,  but  should  be  elliptical  for  large  growths,  in  order  to 
do  away  with  redundancy  after  the  tumor  is  turned  out.     The  capsuln 


FIBROMA.— :MYX0MA.  761 

should  be  opened,  and  the  tumor  may  be  turned  out  almost  wholly  with 
the  fingers. 

Fibroma. — This  variety  of  neojilasm  is  made  up  of  fibrous  tissue,  the 
filaments  of  which  are  at  times  arranged  in  bundles  which  run  in  all 
directions  ;  at  others,  there  is  little  or  no  fascicular  arrangement,  the  fila- 
ments being  entangled  in  all  directions.  In  the  interstices  of  the  bundles, 
or  between  the  fasciculi,  are  found  connective-tissue  cells,  the  poles  of 
which  communicate  with  each  other.  The  vascular  sui^ply  is  limited. 
Fibromata  develop  chiefly  in  the  skin  and  subcutaneous  tissues  and  peri- 
osteum, but  may  exist  in  any  other  portion  of  the  body.  They  are 
usually  single  and  small,  occasionally  multiple,  and  this  form  of  tumor 
may  attain  an  enormous  size.  In  steipe,  those  developing  fi'om  the  deeper 
tissues  are  spherical,  and  are  hard  to  the  touch.  In  the  skin  they  are  often 
pedunculated  and  pyriform.  Fibromata  may  undergo  a  mucoid,  granular, 
or  calcareous  degeneration,  and  are  subject  to  inflammation  and  suppu- 
ration, as  are  other  neoplasms.  Not  possessing  a  high  degree  of  vascu- 
larity, the  danger  of  hemorrhage  is  not  great,  unless  a  rich  granulation- 
tissue  has  sprung  up  as  a  result  of  prolonged  irritation. 

tiimple  fibroma  is  benign,  and  the  indications  in  treatment  are  removal 
by  the  knife. 

Myxoma. — This  neoplasm  is  made  up  of  primitive  connective-tis.sTie 
cells,  similar  to  those  observed  in  the  umbilical  cord  at  birth.  The  cell- 
elements  are  spherical  and  fusifoi-m  in  shape.  The  former  are  isolated 
and  float  freely  in  the  gelatinous-like  intercellular  substance.  The  latter 
may  possess  two  or  more  poles,  and  anastomose  freely  with  each  other, 
forming  a  continuous  network  or  stroma  throughout  the  mass.  The 
vascular  supply  is  rich.  These  neoplasms  occur,  as  a  rule,  in  the  skin 
and  subcutaneous  tissues  and  upon  the  mucous  surfaces,  especially  in 
the  nose  (mucous  or  soft  polypi).  They  may  develop,  however,  in  any 
portion  of  the  body,  and  have  been  observed  in  the  muscles,  bones,  and 
nerves,  the  mammary  gland,  kidney,  brain,  etc.  In  shape,  they  are 
iisually  spherical,  of  small  size,  and  are  soft  and  doughy  to  the  touch, 
and  not  painful  unless  by  accident  the  sensory  nerves  are  pressed  upon 
by  the  tumor.  As  a  result  of  rupture  of  the  blood-vessels,  cysts  fre- 
quently occur  in  this  variety  of  neoplasm. 

The  treatment  is  early  and  complete  removal.  Pure  myxoma  does 
not  tend  to  recur  after  a  tliorough  removal.  In  some  instances,  owing  to 
the  peculiar  location  of  the  neoplasm,  a  thorough  extirj)ation  is  impos- 
sible, and  in  these  cases  the  tumor  may  rapidly  recur.  The  cases  of  gen- 
eral metastasis  after  supposed  myxoma  were  probably  instances  in  which 
the  sarcomatous  nature  of  the  growth  had  been  overlooked. 

Myoma  is  a  tumor  composed  of  new -formed  muscular  elements. 
There  are  two  varieties,  namely,  those  composed  of  striated  or  voluntary, 
and  those  of  non-striated  or  involuntary  muscular  flbers. 

The  flrst  variety  are  extremely  rare,  and  are  of  less  clinical  importance 
than  the  nou-sti'iated  myoma. 

In  two  instances  the  striated  myoma  has  been  seen  in  a  congenital 
tumor  of  the  testicle,  and  in  a  few  other  instances  of  tumors  developed 


762  A   'rEXT-r>OOK   ON   SURGERY. 

wliolly  or  in  part  in  the  embrj'o  or  foetus.     Dermoid  cysts  at  times  con- 
tain traces  of  .striated  niiisclo. 

A  diat/JioNi.s-  can  only  be  made  out  by  the  reco<i'nition,  untler  the  mi- 
croscope, of  the  characteristic  striated  muscular  liber.  The  prof/nosis  is 
favorabh',  owin.<;'  totlie  beuinn  nature  of  the  lumor,  wliicli,  nevertlieless, 
shonkl  be  removed  as  soon  as  recognized. 

In  tlie  non-striated  myoma  the  fusiform  elements  are  arranged  in  all 
directions,  either  in  bundles  or  groups  wliicli  interlace,  or  there  may  be 
a  general  interlacing  of  the  separate  elements  without  fascicular  arrange- 
ment, as  in  many  of  the  organs  in  which  the  smooth  muscle  is  found. 
Between  tliese  bundles  true  connective-tissue  cells  exist,  and  in  these 
spaces  the  vessels  are  found.  The  nuclei  of  these  new-formed  elements, 
as  well  as  the  muscle-elements  proper,  do  not  differ  materially  from  the 
normal  non-striated  muscular  fibers. 

Non-striated  mycmiata  are  often  met  with  in  the  uterus.  In  many  of 
these  neoi)lasms  there  is  a  variable  quantity  of  connective  tissue,  more  or 
less  organized,  and  for  this  reason  the  term  fibro-myoma  has  been  given 
to  these  tumors.  They  may  grow  from  the  wall  of  the  utertis,  toward  the 
peritoneeum  {extra- mural),  or  develop  in  the  substance  of  the  uterine 
mnscle,  become  encapsuled  {intrr-vivral),  or  project  fiom  the  internal 
surface  into  the  cavity  of  this  organ  (.siib-iiincoKH  iiu/oina). 

This  variety  of  neoplasm  has  also  been  seen  in  various  other  localities, 
as  the  skin,  alimentary  canal  at  various  points,  the  prostate,  scrotum, 
etc.  The  diagnosis  depends  upon  the  recognition  of  the  characteristic 
fusiform  elements  under  the  microscope.  The  method  advocated  by 
Comil  and  Ranvier  is  to  macerate  the  sections  in  azotic  acid,  twenty  parts 
to  one  hundred  of  water,  or  caustic  potassa,  forty  parts  to  one  liundreil 
of  water.  By  this  process  the  connective-tissue  stroma  is  dissolved  anil 
the  muscular  elements  liberated. 

The  prognosis  in  this  form  of  myoma  is  favorable  as  far  as  recurrence 
is  concerned  when  the  removal  has  been  thorough.  They  not  infrequently 
produce  death,  either  directly  by  pressure  and  interference  with  the 
normal  functions  of  organs  necessary  to  life,  or  indirectly  by  causing 
haemorrhage,  rendering  the  individual  more  likely  to  perish  from  some 
intercurrent  affection. 

Treatment. — They  should  be  removed,  when  this  can  be  done  with  a 
justifiable  degree  of  safety. 

Neuroma. — A  tumor  composed  of  new-formed  nerve-tissue  is  rarely 
met  with.  Many  so-called  neuromata  are  connective-tissue  neoplasms 
springing  from  the  neurilemma.  They  may  be  made  up  of  nerve-cells  or 
■iwrm-Jihers  (Pig.  709). 

The  former  are  even  rarer  than  the  latter.  Small  particles  of  gray 
matter  have  been  seen  in  dermoid  cysts,  and  in  a  few  instances  neo- 
plasms of  this  variety  have  been  seen  in  the  brain  and  si)inal  cord. 

Fascicular  neuromata  may  occur  in  the  nerves.     They  exist  as  slight 
elliptical  swellings  or  enlargements  of  the  nerve  involved,  may  be  single, 
or  there  may  be  a  succession  of  nodosities  in  the  course  of  the  nerve. 
•  The  symptoms,  in  addition  to  the  tumor,  which  may  at  times  be  made 


ANGIOMA.— LYMPHANGIOMA. 


763 


Fig.  769. — Neuromata  developed  in  the  divided 
nerve-tissues  alter  amputation  of  the  member. 
(After  Cornil  and  Ranvier.) 


out  by  palpation,  are  those  of  pain  or  interference  with  the  function  of 
the  pari  involved.  A  careful  analysis  with  the  microscope  alone  can 
determine  an  accurate  dlcKjiiosh. 

The  prognosis  is  not  grave,  in 
so  far  as  the  life  of  the  jjatient  is 
concerned,  but  the  removal  of  the 
neoplasm  may  of  necessity  involve 
an  injury  of  the  trunk  in  or  upon 
which  it  is  located,  and  in  this 
manner  may  add  an  element  of 
gravity  to  the  result.  They  should 
be  extirj^ated,  and,  where  (as  will 
almost  always  be  the  case)  the  posi- 
tively benign  character  of  the  neo- 
plasm is  not  evident,  a  section  of 
the  nerve  below  and  above  the  tu- 
mor, as  well  as  a  portion  of  the 
surrounding  tissues,  should  be  re- 
moved. 

Angioma. — The  angiomata  are 
tumors  of  new-formed  vessels,  cap- 
illaries, arterioles,  or  veins.     They 

are  frequently  congenital,  and  may  also  appear  at  any  period  after  l)irth. 
Microscopically,  the  simple  forms  are  made  up  of  capillaries,  arte- 
rioles, and  veinules  in  plexuses  richer  than  the  normal,  and  held  to- 
gether by  a  connective- tissue  stroma  of 
varying  thickness.  In  the  more  formi- 
dable tumors — cavernous  need — the  ves- 
sels are  larger,  with  thickened  walls  of 
dense  connective  tissue,  and  at  times  a 
quantity  of  non-striated  muscular  tibers. 
The  vasa  vasorum  are  also  met  with  in 
the  walls  of  the  sinuses. 

The  former  variety  appear  as  red  or 
bluish  spots  or  stains  in  the  skin,  of 
various  sizes  and  shapes,  at  times  rising- 
above  the  level  of  the  integument. 

The  method  of  treat  me /if  is  fully 
described  in  the  chapter  upon  diseases 
of  the  vascular  system. 

Liimpliangioma. — Tumors  composed 
of  new-fonned  lymphatic  vessels  are 
very  rarely  met  with.  In  tlif^ir  construction  they  do  not  materially 
differ  from  the  angiomata.  The  new  tissue  consists  of  a  capillary  net- 
work of  lymph-channels,  in  arrangement  analogous  to  the  capillary  ves- 
sels in  the  smaller  angiomata.  In  other  instances  the  lymph-canals  have 
a  cavernous  arrangement  comparable  to  the  structure  of  the  cavenious 
usevus  above  given. 


Fio.  770.- 


-Anirioma  fcirsoiii  aneuri.sm)  of  tlie 
temporal  region. 


764 


A  TEXT-BOOK   ON   SURGERY. 


Lymphadenoma  has  been  given  under  the  heading  of  "Malignant 
!Neoj)la.sms."  Many  forms  of  enhxrgeniemt  of  the  lympliatic  glands  are  not 
true  tumors,  since  they  are  not  composed  of  now-made  gland-tissue,  are 
due  to  cancerous  infiltraticm,  to  tubercle,  to  syphilitic  adenitis,  tubercu- 
lar deposit,  etc.  Tubercular  lymphoniata  should  always  be  extirpated 
when  tuberculosis  of  the  deeper  organs  can  be  excluded,  provided  that 
the  ojieration  of  removal  does  not  involve  a  too  great  risk  of  life.  The 
removal  of  enlarged  glands  from  metastasis  in  cancer  should  also  be 
done  when  there  is  a  reas()nal)lo  hojie  of  cutting  off  the  disease  from  the 
centers. 

Gfiondroma. — New  fonnations  of  cartilage  develop  in  and  from  the 
connective-tissue  cells  of  any  portions  of  the  body,  excepting  from  carti- 
lage propel'.  The  bones  and  periosteum  are  favorite  points  of  origin  for 
these  neoplasms.  Developing  from  within  the  bone,  a  cartilaginous  new 
formation  is  termed  an  enr-Jtondroma  ;  if  from  the  periosteum,  a  perlcliort- 
droma.  Quite  a  number  of  cliondromata  have  been  observed  in  the  testi- 
cles and  in  the  parotid  glands*.  They  may  assume  all  sorts  of  shapes, 
growing  into  more  or  less  spherical  tumoi's,  or  the  new  tissue  may  be 
generally  diffused  in  the  normal  tissues. 

In  the  bones  of  the  hand  and  fingers  they  give  rise  to  marked  de- 
fonnities  and  to  considerable  pain,  from  displacement  of  the  normal 
structures,  and  interference  with  nutrition  (Fig.  771). 


Fio.  771.— Difl'usc  choQdrom:i  <if  the  phalanges  and  metacarpal  bones,     (.\fter  Nelaton.) 


The  new  formation  of  cartilage  is  preceded  by  an  inflammatory  pro- 
cess varying  in  intensity,  usually  of  a  mild  nature,  yet  resulting  in  the 
proliferation  of  the  cells  of  the  part  involved,  and  the  formation  of  an 
embryonic  tissue  from  which  the  cartilage  is  formed,  as  in  the  normal 
development  of  this  tissue.  Some  of  these  cells  become  the  cartilage- 
cells  proper,  and  are  collected  in  groups  of  different  sizes,  while  others 
foiin  a  connective-tissue  stroma  around  the  collections  of  cartilage-cells. 
The  vessels  find  their  way  along  these  bundles  of  connective  tissue. 


OSTEOMA.  765 

The  proportion  of  connective-tissue  stroma  varies  in  different  tumors. 
When  the  cartihige-cells  and  groups  are  jjlentiful,  with  a  limited  quan- 
tity of  intervening  fibrous  tissue,  the  mass  is  strictly  a  cJtondroma. 
When  the  stroma  i)reponderates,  it  is  termed  a  fibro-fhondroma.  In 
certain  forms  of  these  tumors  there  is  a  paucity  of  connective-tissue  iibers 
as  well  as  cartilage-oells,  although  both  are  present  in  quantity  sufficient 
for  recognition.  The  mass  of  tissue  may  be  emhrijoaic,  and,  under  such 
conditions,  the  tumor  may  be  sarcomatous  in  character.  Simjjle  chon- 
droma is  benign,  liut  a  mixed  chondroma  of  an  embryonic-tissue  type 
must  be  classed  with  the  malignant  neoplasms. 

Chondromata  may  undergo  fatty  or  granular  degeneration,  may  ossify 
in  i)art,  may  become  infiltrated  with  calcareous  matter,  or  undergo  the 
mucoid  change. 

Treatment. — Removal  is  indicated  when  pain  is  unbearable,  or  when 
the  sarcomatous  nature  of  the  neoplasm  is  evident. 

Osteoma. — Tumors  of  new-formed  bone-tissue  may  develop  from  the 
normal  bone  and  periosteum,  or  in  the  tissues  removed  from  the  bones. 
There  are  three  varieties — the  ebuniated,  compact.,  and  spongy. 

In  the  first,  or  ivory-like  neoplasms,  the  bone  is  exceedingly  dense 
and  hard,  and  contains  bone-corpuscles  and  canaliculi  which,  though 
well  marked,  are  more  irregialar  in  arrangement  than  in  normal  forms. 
This  new-formed  bone-tissue,  however,  does  not  possess  blood-vessels. 
These  tumors  are  esi:)ecially  apt  to  be  observed  upon  the  bones  of  the 
skull,  notably  those  of  the  frontal  and  parietal  regions. 

The  compact  or  spongy  neoplasms  are  in  structure  analogous  to  the 
normal  compact  or  spongy  bone-substance.  In  the  latter  the  bony  frame- 
work is  light,  and  the  medullary  spaces  larger  than  normal. 

An  osteoma  formed  upon  the  outside  of  an  old  bone  is  called  an  exos- 
tosis ;  developed  within  the  medullary  space,  an  enostosis. 

Exostoses  grow  as  more  or  less  well-rounded  tumors  beneath  the  peri- 
osteum, or  as  sharp  spikes  or  thorns  projecting  oat  from  the  bone.  Such 
spines  are  in  the  great  majority  of  instances  directed  upward  (stalag- 
mites) in  the  axis  of  the  tendon  in  and  about  which  they  develop.  In 
rare  instances  the  direction  is  downward,  as  seen  in  the  stalactite  (Fig. 
307). 

Bony  neoplasms  may  also  develop  in  any  of  the  cartilaginous  tissues 
of  the  body,  and  this  change  is  usually  one  of  senility.  Beyond  this, 
bone  may  form  in  the  muscles,  choroid,  the  sei'ous  membranes  in  all  lo- 
cations, and  in  the  integument. 

Osteomata  are  always  benign.  If  dangerous  at  all,  it  is  from  com- 
pression of  important  organs.  Those  develo^ied  from  the  internal  surface 
of  the  cranial  bones  and  along  the  vertebral  canal  are  esi)ecially  danger- 
ous in  this  respect. 

Treatment. — Interference  is  not  called  for,  unless  pressure  upon  im- 
portant organs  renders  it  necessary. 


INDEX. 


Abdomen,  wnunds  of,  524 

surgery  of,  477. 

bandage  for,  16. 
Abdominal  abscess.  .517. 

Abdominal  section  for  intestinal  obstruction,  4S9. 
Abscess,  (il,  fi2,  63,  64. 

of  mammary  gland,  465. 

of  chest-wall,  473. 

of  the  liver,  520.  . 

of  the  si)leen,  523. 
Absorbent  cotton,  8. 
Acromion  process,  fracture  of,  288. 
Actual  cautery  as  a  haemostatic,  70. 
Acupressure,  70. 

Adams.     Supra-troehanteric  osteotomy,  714. 
Adenitis,  160.  615. 
Adenoma,  758. 
Alcohol  as  an  antiseptic,  4. 
Alimentary  canal,  obstruction  of,  483. 
Allingham.     Ulcers  of  rectum,  537. 
Allis's  method  of  inducing  ether  narcosis,  26. 
Araussat's  operation  for  colostomy.  516. 
Amputations,  103. 

by  circular  solid  flaps,  106.  107,  108. 

by  oblique  solid  flaps.  111.  112. 

by  circular  skin-flaps.  112.  113. 

by  modified  circular  flaps,  113. 

by  oval  flaps,  113. 

by  double  crescentic  flaps,  113. 

by  double  rectangular  flaps.  114. 

by  mixed  flaps,  114. 

treated  by  the  open  method.  114-116. 

treated  by  continuous  irrigation,  115.  116. 
Amputations,  special,  116. 
Amputation  of  the  fingers,  116-120. 

of  the  thumb.  121. 

of  the  forearm,  123-125. 

at  elbow,  136. 

of  arm,  126-128. 

at  shoulder,  129,  130. 

of  toes,  130. 

of  foot  through  the  metatarsus,  131. 

of  foot  at  the  tarso-metatarsal  joint,  132. 

of  Forbes,  134. 


-imputation  of  Chopart,  135. 

of  Lignerolle.s,  135. 

of  Hancock,  136. 

at  the  tibio-tarsal  joint,  137,  138. 

of  Syme,  137,  138. 

of  Pirogoff,  139. 

of  Le  Fort,  139.  140. 

of  Gunther,  141. 

of  Bruns,  142. 

of  Stephen  Smith,  142-147. 

of  Hey,  134. 

of  Lisfranc,  134. 

of  leg,  142. 

of  Teale.  143. 

of  Sedillot.  144. 

of  Lee.  144. 

at  the  knee,  143,  144. 

at  the  hip,  149,  150. 

of  Erskine  Mason,  150. 

of  the  mammary  gland,  473. 

of  the  penis.  637. 

of  the  prepuce,  639. 
.\n.Tsthesia  and  aniesthetics.  21,  22. 
AucTsthesia  of  the  male  urethra,  621. 
Anchylosis  at  knee-joint.  722. 
.\nderton.  Dr.  W.  B.     Idiopathic   aneurism   of 

both  vertebral  arteries,  224. 
Anel's  method  of  treating  aneurism,  203-205. 
Aneurism,  198. 

Aneurism,  treatment  of,  by  Valsalva's  method, 
201. 

by  Tufnell's  method,  203. 

by  Antyllus's  method,  203. 

by  Wardrop's  method.  203-205. 

by  Anel's  method,  205. 

by  Brasdor's  method.  205. 

by  Hunter's  method,  205. 
Aneurism  of  tlioraoic  aorta,  307. 

of  arteria  innominata,  212. 

of  common  carotid,  216. 

of  subclavian.  218. 

of  vertebn-B,  224. 

of  abdominal  aorta.  234 

of  iliac  arteries,  225. 


768 


A  TEXT-HOOK   ON   SURGERY. 


Aiieurisin  of  femoral  arteries,  226. 

of  popliteal,  227. 

of  tiliiiil  and  peroneal  arteries,  228. 
AiK'nrisiiuil  vnrix,  19!),  228. 
Antcioiiia,  I'Jl,  TU2. 

of  llu'  mainiiiiiry  {.'land,  405. 
Aiiklo-joiiit,  dislocations  of,  340. 

disease  of,  355. 

cxsection  of,  3(i5. 
Anterior  tibial  artery,  209. 
Anthra.K  bac-illus,  80. 
Antisoptie  materials  and  solutions,  3,  4. 
AiitruMi  of  Higlimore,  opening  into  tlio,  425. 
Aiityllns's  method  of  treating  aneurism,  203,  205. 
Anus,  surgery  of,  528. 

absence  of,  528. 

fistula  of,  532. 

fissure  of,  536. 

idcers  of,  537. 

neoplasms  of,  542. 

cancer  of,  542. 

neuralgia  of,  545. 

prolapsus  of,  545. 
Aorta,  aneurism  of,  207,  224. 

deligation  of,  260. 
Areudt.     Ijigafion  of  innominate  artery,  219. 
Auvert.     Ligation  of  subclavian  artery,  220. 
Arm,  bandage  for,  13,  14. 
Arlcria  innominata,  212,  231. 
Arterial  thrombus  and  embolus,  184. 

varix,  186. 

cutaneous  tumor,  191. 
Arteries,  230. 

Arteries,  calcification  of,  173,  174. 
Arterio-venous  aneurism,  228. 
Arteritis,  167. 

syphilitic,  180. 
Artery,  ligation  of  innominate,  231. 

of  common  carotid,  233. 

of  internal  carotid,  238. 

of  external  carotid,  240. 

of  superior  thyroid,  244. 

of  lingual,  244. 

of  facial,  246. 

of  ascending  pharyngeal,  246. 

of  occipital,  246. 

of  posterior  auricular,  248. 

of  temporal  and  internal  maxillary,  249. 

of  subclavian,  249. 

of  vertebral.  255. 

of  internal  mammary,  255. 

of  axillary.  256. 

of  brachial,  257. 

of  ulnar  and  radial,  258. 

of  intercostal,  258. 

of  aorta,  260. 

of  common  iliac,  260. 

of  internal  and  external  iliacs,  262-204. 

of  ghite.ul  and  sciatic  arteries,  263. 

ol  internal  pudic,  264. 


Artery,  ligation  of  femoral,  205,  266,  267. 

of  profunda  femoris,  207. 

of  po|)lileal,  267. 

of  posterior  tibial,  208. 

of  anterior  tibial,  269. 

of  dorsalis  jjcdis,  270. 
Arthritis,  342. 

Articulations,  surgery  of,  310. 
Ascarides  in  the  rectum  and  anus,  .532. 
Aspermatism,  606. 

Aspiration  as  a  means  of  diagnosis  in  al)sces.s, 
61,  62. 

cs  a  means  of  cure  of  abscess,  03,  04. 
Astragalus,  exsection  of,  307. 
Atresia  of  tlu!  aims,  528. 

of  t  lie  rectum,  528,  529. 

Bacteria,  CO,  61. 
Balanitis,  613. 

Bandaging  aTid  bandages,  9. 
Bandage-roller,  9. 

simple  spiral,  10. 

reverse  spiral,  11. 

simple  figure-of-8,  11. 

figin'c-of-8  reverse,  11 

for  h.'ind  and  fingers,  12,  13. 

for  arm,  forearm,  anil  slmulder.  13.  14. 

for  toes,  foot,  leg,  and  thigh,  II,  15,  16. 

spica  (double  and  singl<>),  1(1. 

for  tlie  abdomen  and  thorax,  10. 

for  the  breast,  16,  17. 

for  the  head  and  face,  17, 18,  19,  20. 

knotted,  18. 

for  the  eye,  18,  19. 

four-tail,  19,  20. 
Bands  constricting  the  intestine,  487. 
Banks,  Dr.  E.  A.     L'rethi'otiimy  and  mcatoniy. 

622. 
Banks's  method  of  dilatation  of  stricture  with 

conical  filiform,  026. 
Barlow  on  syphilitic  arteritis,  179-183. 
Barton's  fracture,  295. 
Barwell,  Richard.    Club-foot,  727,  728. 

Operation  for  removal  of  vascular  tumors,  189. 

O.x-aorta  ligatures,  206. 

Ligation  of  carotid  and  subclavian,  211,  213. 

Ligation  of  carotid,  212. 
Basilar  artery,  occlusion  of,  178. 
Bayer.     Ligatif)n  of  subclavian,  220. 
Beall,  Dr.  K.  .1.     Hernia  cei-ebri,  375. 
Bickersteth.     Ligation  of  iimominate,  219. 
Biesiadecki.     The  initial  lesion  of  syphilis.  178. 
Bigelow  on  hip-joint  dislocations,  333,  334,  335, 
336. 

Rapid  lithotrity.  586. 
Bilharzia  ha>matobia,  508,  .580. 
Biliary  calculi  in  the  intestine,  48.3. 
Billroth.     Venous  varis,  195. 

Removal  of  the  tongue,  440, 441. 
Bladder,  503. 


INDEX. 


769 


Bladder,  wounds  of,  5G5. 

ni[)tiire  of,  566. 

Iiaralysis  of,  570. 

aspiration  of,  573. 

punctvire  of,  573. 

new  ionnation  of,  574. 

stone  in,  580. 

foreign  bodies  in,  597. 
Blepharitis,  385. 
Blood-letting,  56,  57. 
Bone-drains,  Neuber's,  7. 
Bones,  snrgery  of,  371. 

of  the  tarsus,  dislocations  of  the,  ■'541. 
Borated  cotton.  8. 
Bow- legs,  731. 

Brachial  artery,  ligation  of,  257. 
Brain,  penetrating  wounds  of,  377. 
Brasdor"s  operation  for  aneurism,  202,  303,  305. 
Braune,  Prof.     Frozen  sections,  134. 
Breast,  lesions  of,  465. 

ampiitation  of,  472. 
Breschet.     Arterial  varix,  187. 
Briddon's  double  tourniquet,  304. 
Broad  ligaments,  G86. 
Broca.     Operation  for  cirsoid  aneurism,  189. 

for  innominate  aneurism,  314. 
Bronchi,  foreign  bodies  in  the,  453. 
Bronchocele,  446. 
Bruns's  amputation,  141,  142. 
Bryant,  Mr.  Thomas.     Ligation  of  carotid  artery, 
312. 
Ligation  of  subclavian,  214. 

Reduction  of  dislocation  of  the  humerus,  335. 

Femoral  hernia,  493. 
Bubanoff.     Process  of  occlusion  of  arteries  after 

deligation,  185. 
Buck,  Dr.  Gurdon.     Extension  in  fracture  of  the 

thigh,  304,  307. 
Bull,  Dr.  W.  T.     Ligation  of  innominate  artery, 

219. 
Bunions,  73G. 
Burns,  90. 
ISutcher.     Ligation   of  carotid   and   subclavian 

arteries,  314. 
Butlin.     Diagnosis  of  epithelioma  of  tongue,  4:37. 
lUizzard  on  syphilitic  arteries,  179,  18.'i. 

Calcaneo-astragaloid  disarticulation,  135. 
Calcification  of  arteries,  176,  177. 
Calculi,  biliary,  483. 
of  the  [irostatc,  ()07. 
of  the  bladder,  580. 
of  the  kidney,  558. 
Callaway  on  diagnosis  of  dislocation  jt  the  shoul- 
der-joint, 333. 
Callisen's  operation  for  colostomy,  j15. 
Cancer,  747. 

Capillary  cutaneous  tumors,  191. 
Ca])illaries.  new  formation  of.  in  inflammation. 
66.  67. 

49 


Carbolic-acid  solutions,  3,  4. 
CarboHzed  gauze,  8. 
Carbuncle,  94,  95. 
Carcinoma,  747. 

of  the  kidney,  560. 

of  the  prostate,  606. 

of  the  |)enis,  035. 
Carden's  amputation,  148. 
Carpus,  fi'acturcs  of,  298. 
Case,  Dr.  Meigs.     Treat  mcnt  of  Pott's  disease, 

703,  710. 
Catgut  ligatures,  1,2. 

sutures,  1,  2. 

drains,  7,  8. 
Cerebral  localization,  378,  380. 
Championniere.     Cerebral  localization,  380,  381. 
Cheiloplasty  of  upper  lip,  41(i. 

of  lower  lip,  417. 
Chest,  wounds  of,  475. 

Chiene.     Osteotomy  for  knock-knee,  719,  730. 
Chloridc-of-zinc  solution,  4. 
Chloroform  narcosis,  24,  33. 
Cholesterin  crystals  in  pus,  60. 
Chondroma,  764. 

of  finger,  745. 
Chopart's  operation,  135,  143. 
Chnimic-acid  catgut,  3. 
Cicatricial  tissue,  07. 
Circumcision,  639. 
Cirsoid  arterial  tumor,  186,  187. 
Clavicle,  fracture  of,  287. 

dislocation  of,  320. 

cxsection  of,  474. 
Cleft-palate,  432. 
Club-foot,  722. 
Club-hand.  740. 
Coagulation-necrosis,  176. 
Cocaine  ana?sthesia,  31,  22,  23. 
('occyx.  fracture  of,  300. 
Cold  as  a  haMiiostatic,  70. 

local  use  of,  in  inflammation.  58,  59. 

as  an  antesthetic,  23. 
CoUes's  operation  for  hare-lip,  414. 

ligation  of  subclavian  artery,  220. 

fracture,  295,  296. 

law.  660. 
Colloid  cancer,  748. 
Colostomy,  514. 
Comnum  carotid  artery,  aneurism  of.  216. 

ligation  of,  233. 
Common  iliac  artery,  ancui'ism  of,  360. 

ligation  of.  260,  261. 
Compinind  fractures  i)f  leg,  315.316. 
Compression,  in  inflammation.  57. 
Condylomata  of  syphilis,  648. 
Congenital  inguinal  hernia,  496. 
Conheim.     Calcification  of  arteries.  170. 
Conjunctivitis,  385,  386. 
Constriction  of  the  intestine  by  bands,  487. 

by  diverticula,  488. 


770 


A  TEXT-BOOK  OX  SURGERY. 


Cooper,   A.      Reduction   of   dislociition   at   tlie 
elbow-joint,  ii'2S. 

Lijiation  of  aorta,  225. 
Cootc,  Holmes.    Serous  cysts  with  angiomata, 

143. 
Coracoid  process,  fracture  of,  288. 
Cornil  and  Kanvier.     Tubercular  ostitis,  699. 

Permanent  occlusion  of  arteries  after  deliga- 
tion,  185. 

Formation  of  angiomata,  192. 

Venous  varis,  195,  190. 

Phlebitis,  l(i3,  104. 

Histology  of  arteries.  168. 

Syphilitic  arteritis,  179. 

Histology  of  the  veins,  161. 

Classification  of  tumors,  746. 

Induration  and  hy])ertrophy  of  the  glands,  748. 

Giant-cells  in  sarcomata.  753. 

Prejiaration  of  myoma.  762. 
Coming's  method  of  producing  cocaine  anaesthe- 
sia, 20-23,  290. 
Corns,  736. 

Corrosive-sublimate  solution.  3,  4. 
Cotton,  borated  and  absorbent,  8. 

styptic,  70. 
Cranium,  fractures  of,  278. 
Crinoline  l)audages,  9. 
Crosby,  Prof.  A.  B.    Treatment  of  aneurism,  204. 

Reduction  of  hip-jniut  dislocation,  335. 
Cruveilliier  on  phlebitis,  196. 

arterial  varix.  186. 
Cyphosis,  691. 
Cystitis,  567. 
Cystocele,  564. 
Cysts  of  the  mammary  gland,  465-469. 

of  the  spleen,  523. 

of  the  kidneys,  559. 
Cysts,  759. 
Czerny-Lcmbert  sul  ure,  480,  491. 

Dacryocystitis,'  391. 

Davidson.    Sypliilitic  arteritis,  179,  183. 
Davis's  apparatus  for  Pott's  disease,  703,  710. 
Deformities  of  the  spinal  column,  691. 

of  the  lower  extremity,  713. 

of  the  upper  extremity,  738. 
Delpech.     Ligation  of  axillary  artery  below  the 

clavicle,  256. 
Denis.     Theory  of  coagulation  of  blood.  163. 
Dennis,  Prof.  F.  S.     Open  method  of  treating 

amputation-wounds,  105. 
Dermoid  cysts.  759. 
Deviations  of  the  septum  nasi,  400. 
Diaphragmatic  hernia.  498-511. 
Dieffenbaeh's  operation  of  rhinoplasty,  402. 
Diphtheritic  conjunctivitis,  388. 
Disea-ses  of  the  joints,  342. 
Dislocations,  319. 
Dislocation  of  the  lower  jaw,  319,  320. 

of  the  clavicle,  320. 


Dislocation  of  the  shoulder,  320,  32L 

of  the  elbow,  326,  327. 

of  the  wrist,  329. 

of  the  phalanges.  329. 

of  the  hip,  329.  330. 

of  the  knee,  338. 

of  the  patella,  339. 

of  the  ankle,  340. 

of  the  tarsus,  341. 

of  the  vertebnc,  341. 

of  the  ribs,  342. 
Dissection-wounds,  81. 
Dobbell's  solution,  399. 
Dorsalis  pedis  artery,  ligation  of.  270. 
Drains  of  rubber,  bone,  catgut,  and  horse-hair,  7, 8. 
Dugas's  diagnosis  of  dislocation  of  the  shoulder- 
joint,  322. 
Duodenum,  oper.itions  upon.  481,  483. 
Dupuytren's  amputation,  130. 

contraction,  743. 

operation  for  restoration  of  the  intestinal  canal 
after  fecal  fistula.  507. 
Durante.     Process  of  permanent  occlusion  of  an 
artery.  185. 

Ear,  surgery  of,  393. 

Ectropion,  389. 

Eczema  of  the  nipple,  465. 

of  the  anus,  531. 
Elbow-joint,  dislocation  at  the,  326,  327. 

disease  of,  358. 

exsection  of,  308,  309. 

amputation  at,  120. 

anchylosis  of,  739. 
Eliot.     Aneurism  of  innominate  artery,  213. 
Embolism,  103,  184. 
Empyema,  474. 
Encephaloid  cancer,  748. 
Endarteritis,  167. 
Enostosis,  765. 

Bnsor.    Aneurism  of  innominate  artery,  213. 
Enteroeele,  494. 
Enterolithes,  483. 
Entropion,  390. 
Epidydimitis,  014,  072. 
Epiphora,  391. 
Epiplocele,  494. 

Epistaxis,  plugging  the  nares  in,  397. 
Epithelioma,  748,  752. 

of  the  anus  and  rectum,  542. 

of  the  nipple,  465. 
Erichsen.     Treatment  of  na?vus,  194. 
Erysipelas,  81-84. 
Erythema  of  the  anal  region,  531. 
Esmarch's  bandage,  9,  40,  09.  70. 

treatment  of  aneurism,  205. 
Ether  and  ether  narcosis,  24,  25. 

spray,  23. 

narcosis  by  rectal  administration,  31,  33. 
Evans.     Aneurism  of  innominate  artery,  214. 


INDEX. 


771 


Exostosis,  745,  765. 

Exsection  of  the  intestine,  491,  507, 

o£  tiie  rectum,  543. 

of  the  hip,  360. 

of  the  Ivnee,  361-305. 

of  the  ankle,  305. 

of  the  astragalus,  307. 

of  the  slioulder,  307,  368. 

of  the  elbow,  308,  309. 

of  the  wrist,  370,  372. 
Exseetions  of  the  joints,  359. 
Extrophy  of  the  bladder,  503,  504. 
Eye,  bandage  for,  18,  19. 
Eyelids,  surgery  of,  383. 

Face,  bandage  for,  17,  18,  19,  20. 

surgery  of,  383. 
Facial  artery,  ligation  of,  246. 
Fecal  fistula,  493,  508,  512.  513,  514. 
Femoral  artery,  aneurism  of,  230. 

ligation  of.  305,  367. 
Femoral  hernia,  508. 
Femur,  fracture  of,  301. 
Fibrin,  theory  of  its  formation,  103,  164, 
Fibroma,  701. 

of  the  nipple,  405, 
Fibula,  fracture  of,  312-315. 
Fingers,  bandage  for,  12, 18. 

amputation  of,  110, 120. 

deformities  of,  741-743. 
Fissure  of  the  anus,  536, 
Fistula  in  ano  et  recto,  532, 
Fletcher,  Dr,  Robert,     Snake-bite,  76,  77. 
Flexion,  of  the  toes,  736, 
Flint,  Prof.  A.     Hydrophobia,  79. 
Fluhrer,   Dr,   W,    P.     Gunshot-wounds  of   the 

brain.  98,  377, 
Foerster,    Classification  of  tumors,  746. 
Foot,  bandage  for,  14,  15. 
Forbes's  amputation,  134. 
Forearm,  amputations  of,  133. 

fractures  of,  293, 

bandage  for,  13,  14, 
Foreign  body  in  the  larynx,  453. 

in  the  trachea,  453, 

in  tlie  bronchi,  453. 

in  the  pharynx,  459, 

in  the  a'sopliagus,  400. 

in  the  intestine,  483. 

in  the  urctlira,  631. 

in  the  bladder,  597. 
Foster.     Coagulation  of  the  blood,  164. 
Four-tail  bandage,  19,  20, 
Fractures,  375. 
Fracture  of  tlie  skull,  278. 

of  the  nasal  bones,  282. 

of  the  upper  jaw,  283. 

of  the  lower  jaw,  284. 

of  the  OS  hyoides,  386. 

of  the  clavicle,  387. 


Fracture  of  the  acromion  process,  288. 

of  the  coracoid  process,  288. 

of  the  glenoid  process,  289. 

of  the  scapula,  288, 

of  tlie  humerus,  289,  290. 

of  the  forearm,  293. 

of  the  ulna,  293, 

of  the  radius,  294. 

of  the  carpus,  298. 

of  the  metacarpus.  298. 

of  the  phalanges,  299. 

of  tlie  sternum,  299. 

of  the  ribs,  299, 

of  the  vertebra?,  300. 

of  the  sacrum,  300. 

of  the  coccyx,  300. 

of  the  OS  innominatum,  301. 

of  the  femur,  301. 

of  the  patella,  308, 

of  the  leg.  312. 

compound,  of  the  leg,  315. 

of  the  tarsus,  317. 
Freund's  operation  of  hysterectomy,  681. 
Frey,  pathology  of  phlebitis,  161,  163. 
Frost-bite,  94, 
Furuncle,  94. 

Galactocele,  409, 
Gangrene,  97-101. 

Gant's    line    for    sub -trochanteric    osteotomy, 
714. 

operation  for  removal  of  tongue,  440,  441. 
Gastrectomy,  478, 
Gastro-enterostomy,  478,  480,  481. 
Gastrostomy,  462,  477. 
Gauzes,  8. 

Genito-virinary  organs,  555, 
Genu  valgum,  716, 

varum,  721. 
Gcrster,  Prof,  A.  G,     Aneurism  of  innominate, 

213, 
Gibney,  Prof,  V.  P,     Myelitis  from  compression 
in  Pott's  disease,  711. 

Ostitis  of  head  and  neck  of  femur,  345. 
Girdner,  Dr.  .1,  H.     Skin-grafting,  92, 
Glanders,  79,  80, 

Glenoid  process  of  scapula,  fracture  of,  289, 
Gleet,  617, 
Glossitis,  435. 
Gluteal  artery,  ligation  of,  263. 

hernia,  498-513. 
Goitre,  446. 
Gonorrhoea,  60S,  609. 
Gonorrhoea!  i-heumatism,  016. 

ophthalmia,  388, 
Green.     Formation  of  thrombi,  164. 
Greenfield,     .Syphilitis  arteritis,  179-183. 
Gritti's  amputation,  148, 

Gross,  Prof,  S,  W,    Ligation  of  internal  ju^ar 
vein,  249. 


772 


A  TEXT-BOOK  ON  SURGERY. 


Gunshot-wounds,  87,  88,  89. 

missiles,  88. 
Gunther's  amputation,  V.V.). 

Iln'inaturia,  578. 

Ila'inonliase,  arrest  of.  .lO,  68,  69,  70. 

IlaMuorrlioiils,  547. 

Hallux  valgus,  735. 

varus.  7;i6. 
llamiltun,  Prof.  F.  II.     Tetanus,  85. 

Phleliilis,  164. 

Fracture  of  malai'  bone,  283. 

Fract  ure  of  lower  jaw.  285. 

Fracture  of  humerus.  '2'.)Z. 

Fracture  of  radius.  297. 

Fracture  of  thigh.  304. 

Fracture  of  patella.  30!),  310. 

Dislocation  at  elbow.  329. 

Dislocation  of  hip-joint,  337,  338. 
Hammer-toes,  73G. 

Hancock's  modification  of  Malgaigue's  operation, 
136. 

operation  of  peritonitis.  51G. 
Hand,  bandage  for,  12,  13. 

amputation  of,  122. 

deformities  of,  740. 
Ilanilkerchief  bandages,  19,  30. 
Ilare-lip,  410. 
Head,  surgery  of,  373. 

bandages  for,  17-20. 

net,  20. 

and  chin  bandage,  17,  18. 
Heart-failure  in  ether  and  chloroform  narcosis, 
31. 

wounds  of,  476. 
Heat  as  a  hieraostatic,  70. 
Heaton's  operation  for  hernia,  502. 
Heitzmann.     Histology  of  the  veins,  161,  162. 

Of  the  arteries.  168. 
Henry's  amputation  of  scrotum,  071. 
Hepatic  abscess,  520. 
Hernia  cerebri.  375. 

strangulated  inguinal.  504. 

of  the  spleen,  523. 

of  the  bladder,  564. 
Hernia.  493. 

inguinal,  494. 

femoral.  4!)6,  508. 

umbilical,  497,510. 

ventral,  497.  511. 

diaphragmatic,  498,  511. 

gluteal,  498,  512. 

obturator,  498,  513. 

lumbar,  498,  512. 

vaginal.  498,  512. 

diagnosis  of.  498-500. 

treatment  of,  501. 
Herpes  of  the  anal  region,  531. 
Heubner.     Syphilitic  arteritis,  179. 
Hey's  amputation,  133,  143. 


Hip-joint,  dislocations  at  tlie,  339. 

disease,  344. 

exsection  of,  360,  361. 

deformities  at  the,  713. 

osteotomy  near  the,  714. 
Hood-liandage,  20. 
Hordeolum,  385. 
Horse-hair  drains,  7.  8. 
Humerus,  fracture  of,  389,  290. 
Humphrey'soperation  for  cancer  of  the  penis,  037. 
Hunter's  method  of  ligation  of  arteries  in  aneu- 
rism, 202,  203,  205. 
Hutchinson.     Syphilitic  ))hlebitis,  164,  165. 

Multii)le  na^vi.  193. 
Hydatids  of  the  liver.  .523. 
Hydrocele  of  the  tunica  vaginalis  testis,  C64. 

of  the  cord,  664. 
Hydronephrosis.  557. 
Hydrophobia,  78,  79. 
Hyoid  bone,  fracture  of,  286. 
Hypertrophy  of  the  prostate,  598. 

of  the  mammary  gland,  407. 
Hysterectomy.  691. 
Hysterotomy,  678. 

Ileo-colostomy.  493. 

Iliac  arteries,  aneurism  of,  285. 

ligation  of,  262.264. 
Incontinence  of  m'ine,  514. 
Infantile  hernia,  496. 
Inferior  ma.xilla,  fracture  of,  284 

dislocation  of.  319,  330. 
Infiltration  of  urine,  506. 
Inflammation,  53-55,  56,  57,  58. 
In-growing  nail,  737. 
Inguinal  hernia.  494. 

congenital,  496. 
Inhalers  for  ether,  25,  26,  37. 
In-knee.  717. 
Innominate  artery,  aneurism  of,  213. 

ligation  of,  331. 
Instruments,  34. 

Intercostal  artery,  ligation  of,  258. 
Internal  pudic  artery,  ligation  of,  364. 

carotid  artery,  ligature  of,  238. 

mammary  artery,  ligature  of,  255. 

iliac  artery,  ligature  of.  262. 
Intestine,  constriction  by  bands,  487. 

constriction  by  diverticula,  487,  488. 

abdominal  section  in  occlusion  of,  489,  490. 

exsection  of  a  porti(m  of,  491. 

wounds  of,  536,  527. 
Intussusception,  483,  484. 
Iodoform  solution,  4. 

gauze,  8. 
Irrigation,  continuous,  115,  116. 
Irrigators,  4,  5. 

Janew,ay.  Prof.  E.  G.     Albuminuria  .after  mental 
labor,  577. 


INDEX. 


77: 


Jarvis's  snare,  398,  399. 
Jequirity-bean  in  panniis,  387. 
Jork-finger,  743. 
Joints,  surgery  of,  319-343. 
Juniper-oil  catgut,  1,  2. 

drains,  7. 
Jute,  8. 

Kidneys,  surgery  of,  5.55. 

neoplasms  of,  559,  5(!0. 
King,  Dr.  E.  P.     Snake-bite,  76. 
Knee,  anchylosis  of,  722. 
Knee-joint,  dislocations  at  the,  338. 

disease  of,  353. 

exsection  of,  3G1,  305. 
Knock-knee,  717. 
Knotted  bandage,  18. 
Koch.     Corrosive    sublimate    as   an   antiseptic 

agent,  3. 
Kocher"s  operation  for  r(?moval  of  tongue.  440, 
441. 

extirpation  of  thyroid  body,  448. 
Koenig's  operation  for  rhinoplasty,  402. 
KoUer.    Introduction  of  cocaine  aniBsthesia  by, 

21. 
Krackowizer.    Spontaneous  cure  of  cirsoid  aneu- 
rism, 190. 

Ulcer  of  appendix  vcrmiformis,  513. 
Kunkler,  Dr.  (r.  A.    Snake-bite,  76. 

Labat's  operation  for  rhinoplasty,  402. 
Lacerda,  de,  on  the  treatment  of  snake-bite.  77. 
Lange,  Dr.  F.     Ligation  of  common  iliac,  226. 
Langenbeck's  operation  for  rhinoplasty,  402. 

for  hare-lip,  413. 

osteoplastic  exsection  of  upper  jaw,  425. 
Laparotomy  for  intestinal  occlusion,  489,  490. 

for  removal  of  the  ovaries,  etc.,  688. 
Larrey's  amputation  at  the  shoulder,  130. 
Laryngectomy,  456. 
Laryngotomy,  450. 
Larynx,  surgery  of,  450. 

intub.ation  of  the,  451,  452. 

foreign  bodies  in  the,  453. 
Lateral  curvature  of  the  spine,  694. 
Lee's  amputation  of  leg.  14:J,  144. 
Leeches,  aiiplication  of,  57. 
Le  Port's  amputation,  139,  140.  142. 
Leg,  bandage  for  the,  14,  15,  16. 

amputations  of,  142. 

fractures  of,  312. 
Lembert's  suture  for  tlic  intestine,  480,  491,  526. 
Leopold's  operation  of  hysterostomy,  679. 
Levis's  operation  for  extrophy  of  bladder,  564. 

for  hydrocele,  667. 
Ligature  material.  1,  3,  3. 
Ligatures,  method  of  applying,  50.  51. 
Lignerolle's  amputation,  135. 
Lingual  artery,  ligation  of,  244. 
Linhart's  operation  for  rhinoplasty,  403. 


Lipoma,  760. 

Lips,  surgery  of,  407. 

Lisfranc's  amputation,  134. 

Lithotomy,  589. 

Lithotrity,  585. 

Little,  Prof.  J.  L.    Innominate  aneurism,  213. 

Median  lithotomy,  595. 
Littre's  anterior  or  intra-peritoneal  colostomy, 

595. 
Liver,  surgery  of  the,  530. 
Local  anajsthesia,  21,  22,  23. 
Lock-jaw,  84,  85,  86,  87. 
Loffler.     Bacillus  of  glanders,  80. 
Lower  extremity,  deformities  of,  713. 

jaw.  fracture  of,  284. 
Lucas-Championniere.  Cerebral  localization,  378. 
Lumbar  hernia,  498.  512. 
Lu|)us  of  the  nose,  cheeks,  and  lips,  408. 
Lymphadenoma,  752,  764. 
Lymphangioma,  763. 
Lymphatic  vessels,  diseases  of,  158. 

glands,  diseases  of,  160. 
Lymphatics,  wounds  of,  161. 

Macewen's  operation  for  knock-knee,  719,  730. 

chromic-acid  catgut,  3. 
MacCormac's  operation  for  genu  valgum,  720. 
Mackintosh  cloth  for  protective,  8. 
Macnamara's  operation  for  incipient  ostitis  of 

head  and  neck  of  femur,  352. 
Malgaigne's  operation  for  hare-lip,  413. 

at  calcaneo-astragaloid  articulation,  135,  136. 
JIalignant  pustule.  80. 
Mammary  gland,  465. 

hypertrophy  of,  467. 

tumors  of,  467. 

extirpation  of,  471.  472. 

bandage  for,  16,  17. 
Marion-Sims,  Dr.  H.     Drainage  of    peritoneal 
cavity,  566.  689. 

Ether-inhaler,  27. 
Martin's  rubber  bandage,  9,  96,  196. 
Mason,  Dr.  L.  D.    Fracture  of  bones  of  nose, 

282. 
Mason,  Prof.  Erskine.    Amputation  at  hip,  151. 
Mastitis.  466. 
Maxilla,  superior,  423. 

inferior,  437. 
Meatomy,  632. 

Meckel's  ganglion,  removal  of,  435. 
Mesarteritis,  167. 
Metacarpus,  fractures  of,  298. 
Metatarsus,  amputations  through  the.  131. 
Micrococci.  GO,  61. 

Jlitchell.  Prof.  S.  Weir.    Snake-venom.  76. 
Moles,  196. 
Moore.  Pnif.    Fracture  of  clavicle,  287,  288. 

Colles's  fracture.  396. 
Morbus  coxarius.  342. 
Mucous  cysts,  760. 


774 


A  TEXT-BOOK  OX   SURGERY. 


Miiller.     Recurrent  angioiiiii,  193. 

Miillor's  law,  740. 

Muslin  banilages,  9. 

Mussey.     Arterial  varix,  188. 

Myelitis  from  cunipression  in  Pott's  disease,  711. 

Myoma.  761. 

Myxonui,  7G1. 

Na-vus  pigment osus,  197. 

pilosus,  197. 
Nail,  in-growing,  737. 
Nasal  bones,  fracture  of  the,  283. 
Neck,  surgery  of,  444. 
Neoplasms  of  the  intestine,  488. 

of  the  urethra,  (!34. 
Nephrectomy,  5(i2. 
Nephrotomy,  5()2. 
Neuber's  bone-drains,  7. 
Neuralgia  of  prostate,  608. 
Neuroma.  762. 
New  formations,  746. 
Nipple,  Assure  of,  465. 
Nose,  bleeding  from,  397. 

foreign  bodies  in  the,  397,  398. 

deviation  of  septum,  400. 

plastic  surgery  of,  400. 

Obstnietion  of  the  alimentary  canal,  483. 

Obturator  hernia,  498-512. 

Occipital  artery,  ligation  of,  340. 

O'Dwyer,  Dr.  J.     Intubation  of  larynx,  451,  452. 

(Esophagectomy,  463. 

Q5sophagi)tomy,  401. 

CEsojihagus,  surgery  of,  459. 

stricture  of,  461. 
Ogston's  opei-ation  for  knock-knee,  719,  720. 
Oil-silk  protective.  8. 

Operating-i-oom  and  paraphernalia,  43,  45. 
Operation,  a  snrgical,  49.  50. 

assignment  of  duties,  106. 
Ophthalmia  neonatorum.  386. 
Orbital  cavity,  surgery  of,  392. 
Orchitis,  615,  673,  674. 
Os  innominatum.  fracture  of,  300,  301. 

hyoides,  fracture  of,  286. 
Osteo-arthritis,  342. 
Osteoclasis.  721. 
Osteoma,  765. 
Osteomalacia,  274. 
Osteotomy  of  femur.  714. 
Ostitis,  271. 

Otis.  Prof.  P.  N.    Location  of  stricture,  620. 
Otis,  Dr.  G.  A.     Shot-wounds  of  face,  382. 
Otitis  media.  395,  396. 
Ovaries,  683. 
Ovariotomy.  688. 
Oza-na,  399. 

Paget.     Transformation  of  embrj'onic  into  cica- 
tricial tissue,  67. 


Paget.     Gouty  phlebitis,  165. 
Palate,  surgery  of,  431. 
Pancreas,  524. 
Pannus,  387. 
Papilloma,  757. 
Papilloma  of  nipple,  46.5. 
Parotid  gland  and  duct,  420. 
Parotitis,  423. 

Pasteur  on  hydroi)hobia,  78. 
Patella,  fracture  of,  308. 

dislocation  of.  339. 
Peat  as  an  absorbent,  8. 
Penis,  surgery  of,  634. 

ulcers  of,  641. 
Periarteritis,  167. 
Perineal  lithotomy.  590. 
Periorchitis.  6(i3. 
Perispermatitis,  603. 

Peritonitis,  laparotomy  on  account  of,  516. 
Perityphlitis,  517,  518! 
Peroneal  artery,  ligation  of,  268,  269. 
Phalanges,  fracture  of,  299. 

dislocation  of,  329. 
Pharynx,  surgery  of,  459. 
Phimosis,  638. 
Phlebitis,  161. 
Phlebolites,  191-190. 
Phlyctenular  conjunctivitis.  389. 
Pitcher,  Prof.  L.  S.    Colles's  fracture.  296. 
Piles,  547. 
Pirogoff's  method  of  rectal  etherization,  31,  33. 

amputation,  134,  139,  142. 
Pityriasis  versicolor  of  anal  region,  531. 
Playfair.     Laparotomy  for  peritonitis,  510. 
Pneumatocele  of  the  head,  374. 
Polydactylus,  734,  741. 
Polypus  of  the  rectum,  514. 
Pope,  Dr.  Thomas  A.     Tarantida-poison,  78. 
Popliteal  artery,  ligation  of,  267. 

aneurism  of,  227. 
Porro's  operation  for  hysterectomy,  680. 
Port-wine  mark,  197. 
Posterior  auricular  artery,  ligation  of,  248. 

tibial  artery,  ligation  of,  2G8. 
Posthitis,  613. 
Potfs  disease,  699. 

fracture,  313,  315. 
Prepuce,  divulsion  or  dilatation  of  the,  641. 

amputation  of,  639. 
Profunda  femoris  artery,  ligation  of,  267. 
Prostate  body,  surgery  of,  597. 

tuberculosis  of,  606. 

cancer  of,  606. 

sarcoma  of,  607. 

calculus  of,  607. 

neuralgia  of,  608. 
Prostatorrhcca,  604. 
Protective,  8. 
Pruritus  ani,  530. 
Ptosis,  390. 


INDEX. 


775 


Pus,  59,  60,  61. 

Pyelitis,  550. 
Pylorectomy,  478. 

Rabies,  78,  79. 

Kaeliitis,  374. 

Radial  ai-tery,  ligation  of,  258. 

Radius,  fracaure  of,  294. 

Ranula,  441. 

Ranvier.    See  Cornil  and  Ranvier. 

Rectal  etherization,  31,  33. 

Rectum,  surgery  of,  538. 

foreign  bodies  in,  533. 

fistula  of,  533. 

ulcers  of,  537. 

stricture  of,  539,  540. 

neoplasms  of,  542. 

carcinoma  of,  543. 

exsection  of,  543. 

neuralgia  of,  545. 

prolapsus  of,  545. 
Reeves's  operation  for  knock-knee,  719,  730. 

club-foot,  730,  732. 
Regional  surgery,  373. 
Reichert,  Dr.  E.  J.     Serpent-venom,  76. 

Coagulation  of  blood  in  the  vessels,  1(34. 
Renal  calculus,  558. 

colic,  559. 

cysts,  559. 
Resuscitation  from  ether  and  cliloroform  narco- 
sis, 29,  30,  31. 
Retropharyngeal  abscess,  703. 

peritoneal  abscess,  519. 
Rheumatism  in  gonorrhoja,  616. 
Rhigoline,  33. 
Rhinolites,  398. 
Rhinoplasty,  401. 
Rib,  exsection  of,  473-475. 
Ribs,  fracture  of,  299. 

dislocation  of,  343. 
Richardson's  ether-spray  apparatus,  33. 
Rick(-ts,  274. 

Rindflcisch.     Formation  of  angeioraata,  193. 
Roberts,  Dr.  John  B.     Deviation  of  the  septum, 

400. 
Robin,  arterial  varix,  186,  187. 
Roliinson,  Prof.  A.  R.     Lu))us,  408. 

Carbuncle,  94. 
Rokitansky.     Origin  of  angeiomata,  193. 
Rotary-lateral  curvature  of  the  spine,  691-094. 
Rubber  drainage-tubes,  7. 

tissue-protective,  8. 

Sacrum,  fracture  of,  300. 
Saenger's  operation  for  hysterostomy,  679. 
Saline  solution,  intravenous  in'eetion  of,  74,  75. 
Salpingitis,  083. 

Sands,  Prof.  11.  B.    Ijigation  of  carotid  and  sul)- 
clavian  artery.  210. 
Compression  of  iliac  artery,  226. 


Sands,  Prof.  IT.  B.    OSsophagotomy,  401. 

Sarcoma,  753-756. 

Savage.    Laparotomy  for  peritonitis,  510. 

Sawdust  as  an  absorbent,  8. 

.Sayre,  Prof.  L.  A.     Operation  at  the  liip,  300,  361. 

Club-foot,  723,  724,  736,  739. 

Polydactylus,  734. 

Fracture  of  clavicle,  380,  287. 

nip-joint  disease,  350.  353. 

Hip-joint  exsection,  359,  300. 

Muscular  torticollis,  093. 

Treatment  of  knock-knee,  719. 

Osteotomy  of  femur,  714. 

Treatment  of  Pott's  disease,  703,  704,  705,  707. 
Scalds,  90. 

Scapula,  fracture  of,  388. 
Scarification  in  inflammation,  57. 
Schmidt.     Coagulation  of  blood,  104,  176. 
Schrooder's  operation  for  hysterectomy,  681. 
Sehutz.     Glanders  bacillus,  80. 
Scirrhus  cancer,  748. 
Scoliosis,  691-694. 
Scrotum,  surgery  of,  661. 
Sebaceous  cysts,  759. 
Sedillot's  amputation,  143,  144. 
Senile  gangrene,  100. 
Septum  nasi,  deviation  of,  400. 
Serous  cysts,  7()0. 
Shaiter's  apparatus  for  Pott's  disease,  707,  708, 

709. 
Sheppard,  Dr.  F.  C.     Statistics  of  amputation  at 

hip-joint,  155. 
.Shoulder,  bandage  for,  13,  14. 
Shoulder-joint,  amputation  at  the,  129,  130. 

dislocations  of  the,  320. 

disease  of  the,  357. 

exsection  of  the,  3(i7,  308. 

anchylosis  of  the,  738. 
Silk  sutures,  2. 

-worm  gut,  2,  3. 
Silver-wire  sutures,  3. 

Sims,  Dr.  J.  JIarion-.   Exploration  of  rectum,  533. 
Skin-grafting.  91,  92,  93. 

transplantation  of,  93. 
Skull-net,  20. 
Skull,  fracture  of,  278,  281. 

penetrating  wounds  of.  377. 
Smith,  Prof.  Stephen.     Amputations  of  leg,  142, 

143,  14(i.  147.  14S. 
Snake-liito.  75.  7(i,  77. 
Snap-finger,  743. 
Solutions,  antiseptic,  3,  4. 
Sounds,  629. 
Spermatorrhoea,  600. 

Spica,  single  and  double,  for  the  groin,  10. 
Spina  bifida,  711. 

Spinal  column,  deformities  of,  691. 
Spleen,  sui-gery  of,  523. 

abscess  of.  523. 

cysts  of,  523. 


776 


A  TEXT-BOOK   ON  SURGERY. 


Spleen,  hernia  of,  523. 

Splencc-tomy.  523. 

.Spondylitis,  Gi)». 

Sponges,  preparation  and  preservation  of,  5,  6,  7. 

Spray-machine,  Dr.  Weir's,  4 

Staphylorraphy.  432. 

Starr,  Dr.  M.  Allen.    Cerebral  localization,  379, 

380. 
Staton,  Dr.  L.  L.    Gastrostomy,  403. 
Sternum,  fracture  of,  299. 

cxsection  of.  474. 
Stimson,  Prof.  L.  A.    Fracture  of  thigh  through 

the  trochanters,  SOO. 
Stomach,  surgery  of,  477. 

foreign  bodies  in,  477. 

exsection  of  a  portion  of,  478. 
Stone  in  the  bladder,  580. 
Strangulation  of  intestine  by  bands.  487. 

by  slits  in  omentum.  4S7. 

by  diverticula,  487.  488. 
Strangulated  hernia.  504. 
Stricture  of  the  intestine,  488,  489. 

of  the  rectum.  540. 

of  the  urethra,  018. 

of  the  urethra,  location  of,  021. 

of  the  urethra,  treatment  of.  023. 

of  the  urethra,  dilatation  of,  020,  029. 

of  the  oesophagus,  401. 
Stye,  385. 
Styptic  cotton,  70. 
Subclavian  artery,  aneurism  of,  218. 

ligation  of.  249. 
Sublimate  gauze,  8. 
Submaxillary  gland.  423. 
Sub-trochantcric  osteotomy,  714. 
Superior  thyroid  artery,  ligation  of,  244. 

maxilla,  fracture  of,  28:5. 
Suppression  f)f  urine,  500. 
Suppuration.  59,  00. 
Supra-pubic  lithotomy,  589. 
Surgical  dressings,  1. 

method  of  applying,  52. 
Sutton.    Dr.    R.    S.      Essection    of    intestine, 

491. 
Suture-material,  preparation  and  preservation  of, 

1,  2,  3. 
Suture,  interrupted,  72. 

continuous,  72. 

mattress,  72,  73. 

quill,  72.  73. 

wire,  72,  73. 

pin,  73. 

cross,  73. 

double-needle.  7-'?. 
Sylvester's   method  of  resuscitation   applied  in 

ether  and  chloroform  narcosis,  30,  31. 
.Symblcpharon,  389. 
Syme's  amputation,  137,  138. 
Syndactylus,  734. 
Svndcsmitis,  343. 


Synovitis,  342. 
Syphilis,  045.  001. 
.Syphilitic  arteritis,  180-187. 
occlusion  of  the  basilar  artery  in,  178,  179. 

Tait,  Jlr.  Lawson.    Laparotomy  for  peritonitis, 

510. 
Talipes,  722. 

equinus,  722.  724. 

calcaneus,  725. 

varus,  720. 

etjuino-varus,  720-730. 

valgus.  731. 

cavus,  733. 

planus.  733. 
Tarso-metatarsus,  amputation  through,  132. 
Tarsotomy,  731. 
Tarsus,  amputation  through,  132. 

dislocations  of,  344 

fractures  of,  307. 
Taxis,  504 
Taylor,  Dr.  C.  F.    Treatment  of  Pott's  di.scase, 

703. 
Tcale's  amputation,  143,  144 
Teeth,  4;». 
Testicle,  073. 
Tetanus,  84-87. 
Textor's  amputation,  135. 
Thecitis.  342. 

Thigh,  bandage  for,  14,  10. 
Thompson,  Sir  Henry.    Operation  for  lithotrity, 
580. 

Continuous  dilatation  of  stricture  of  the  ure- 
thra, 027. 
Thorax,  bandage  for,  16. 

surgery  of,  405. 
Thrombosis  of  the  veins,  103. 

of  the  arteries,  184. 
Thumb,  amputation  of,  121. 
Thyroid  body,  440. 
ThyTotomy,  450. 
Tibial  artery,  aneurism  of,  228. 

ligation  of,  208. 
Tibio-tarsal  joint,  137.  138. 
Toes,  deformities  of.  730. 

amputation  of,  130. 

bandage  for,  14,  15. 
Tongue.  435. 

method  of  controlling  hiemorrhage  in  ampu- 
tation of,  439. 

-tie,  442. 
TonsiLs,  442. 
Torsion  of  arteries,  70. 
Torticollis,  091. 
Tourniquets,  08,  70. 
Trachea,  450. 

foreign  bodies  in,  453. 
Tracheotomy,  451. 
Trachoma,  .386. 
Transfusion,  74,  75. 


INDEX. 


777 


Treeves,  P.     Intestinal  obstruction,  intussuscep- 
tion, 4S5. 
Trendelenburg's  trachea-tampon,  457. 

araputation  at  hip,  150. 
Trepliiuing  the  skull,  381,  383. 
Trichiasis,  391. 

Tuberculosis  of  the  prostate,  GOG. 
Tufnell's  method  of  treating  aneurism,  203,  208, 

225. 
Tumors,  74G. 

of  the  scalp,  .373. 

of  the  bladder,  574. 
Typhlitis,  517,  518. 

rieers.  96,  97. 

of  tlie  rectum  and  anus,  537. 
Ulnar  artery,  ligation  of,  258. 
Tl'mbilical  hernia,  497,  510. 
Upper  extremity,  deformities  of,  73S. 
Ureters,  surgery  of,  5G3. 
Uretlira,  surgery  of,  GOS. 

cocaine  an.-esthesia,  G31. 

foreign  bodies  in,  G31. 

congenital  malformations,  G33. 

neoplasms  of,  G34. 
Urethritis.  GOS. 
Urethrotomy,  iutemal,  G23,  G24 

external,  G37,  028. 
Urine,  infiltration  of,  5GG. 

incontinence  of,  574. 

analysis  of,  575. 

suppression  of,  5G0. 

Vagina,  hernia  into  the,  408-513. 

Valsalva's  method  of  treating  aneurism,  201-208, 

221  222 
Van  Buren.     Xormal  curve  of  the  uretlira,  G30. 
Vance,  Dr.  A.  M.     Corsets  for  spinal  curvature, 

G97. 
Varicocele.  GG3. 
Varicose  aneurism,  199. 

veins,  194. 
Vascular  system,  surgei-y  of  the,  158. 

(umors,  18G. 
Vas  deferens,  671. 

Vein,  ligation  of  internal  jugular,  233-249. 
Velpeau's  bandage  in  disloitation  of  the  acromial 

end  of  the  clavicle,  321. 
Venesection,  56,  57, 
Venous  cutaneous  tumor,  191. 
varLx,  194. 


Ventral  hernia,  497-511. 

Verneuil's  operation  for  hydatids  of  liver,  533. 

Vertebra,  fractures  of,  300. 

dislocations  of,  341. 
Vertebral  artery,  ligation  of,  255. 

aneurism  of,  224. 
Vesicular  semiuales,  671. 
Virchow.     Classification  of  tumors,  746. 

phlebitis,  1G3,  164. 
Volkmann's  sharp  spoon  in  gangrene,  103. 

sliding  foot-piece  for  fracture,  304. 

operation  for  hydrocele,  G67. 
Volvulus,  486. 

Wardrop's   method   of   treating   aneurism,  203, 

203. 
Wardwell,  Dr.  W.  L.   On  calcification  of  arteries. 

IGO,  101. 
Warren,  J.  Mason.     Angeioma  following  frost- 
bite, 192. 
Wassilieff.    Bacillus  of  glanders,  80. 
Weber,  Dr.  L.     Occlusion  of  basilar  artery,  178. 
Weber,  0.  Process  of  occlusion  of  an  artery  after 

tlie  application  of  a  ligature,  185. 
Web-fingers,  741. 
Webster,  Dr.  David,  on  jequirity-bean  in  pannus, 

387. 
Weigert.    Coagulation-necrosis,  176. 
Weir's  antiseptic  spray-machine,  4. 
Wire-eoi-aseur  of  Jarvis,  399, 
Wolfler's  operation,  480,  481. 
Wood,  Prof.  J.  R.     Open  treatment  of  amputa- 
tion-wounds, 105. 
Wood-wool,  8. 
Wounds,  65. 

closure  of,  71-74. 

poisoned.  75-78. 

gunsliot,  87-89. 

of  tlie  lymphatic  vessels.  100,  161. 

of  the  chest,  475. 

of  the  heart,  476. 

of  the  abdomen  and  viscera,  524. 

of  the  kidney,  555. 

of  the  bhidder,  505. 
Wrist-joint,  amputations  at,  123. 

dislocations  at,  329, 

disease  of,  358. 

exsection  of,  370-372. 
Wry-neck,  091. 

Zinc  chloride,  solution  of,  4. 


THE    KND. 


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A  MANUAL  OF  OPERATIVE  SURGERY. 

By  JOSEPH   D.  BRYANT,  M.  D., 

Profeepor  of  Anat<imy  and  Clinical  Surgery,  and  Associate  Professor  of  Orthopa?dic  Surgery  in 
Bellevne  Hospilal  Medical  College;  Visiting  Surgeon  to  Btllevne  and  St.  Vincent's  Hos- 
pitals, and  Consulting  Surgeon  to  the  New  York  Lunatic  As; lam,  etc. 


NEW  EDITION,  REVISED  AND  ENLARGED. 

Sro,  330  payee  and  703  lUiislrations.  Cloth,  $5.00;   sheep,  $6.00. 


We  invite  the  attention  of  students  and  practitioners  of  medicine  to  the 
following  opinions  and  notices  of  this  sterling  work: 

Dr.  J.  WiLLiSTON  Wright,  Profexmr  of  Surgery  in  the  Medical  Dcparimeni  of  the  Uni- 
versitif  of  the  City  of  New  York,  and  in  the  Aledieal  Department  of  the  University  of 
Vermont,  writes: 

"  The  concise  and  systematic  mauner  in  which  the  accomplished  author  has  treated  the 
subject  meets  my  hearty  approval ;  and  a-s  a  book,  fully  up  to  the  times  in  whatever  the 
crucial  test  of  experience  has  assijined  a  definite  place  m  our  art,  should  commend  itself 
alike  to  students  and  practitioners  of  medicine  and  surgery." 

Dr.  RoswELL  Park,  Professor  of  the  Principles  and  Practice  of  Surgery  and  Clinical 
Surgery  in  the  Medical  Department  of  the  University  of  Buffalo,  writes: 

"...  It  is,  according  to  my  notion,  the  best  work  of  its  kind  now  before  the  public, 
and  I  shall  take  ?reat  pleasure,'  not  only  in  commending  it  to  others,  but  in  making  it  my 
own  guide.  .  .  ." 

Dr.  C.  T.  Parkes,  Professor  of  Surgery  in  Rush  Medical  College,  Chicago,  writes: 

"  It  gives  me  great  pleasure  to  express  my  opinion  of  the  excellence  of  Dr.  Bryant's 
'  Manual  of  Operative  Surgery.'  For  clearness  of  dcscriiition,  preoi.-'ion  of  statement,"ordcr 
in  the  arrangement  of  subjects,  and  faithfulness  in  illastration,  the  work  surpasses  anything 
of  the  kind  in  my  possession." 

"...  We  know  of  no  better  work  on  operative  surgery  to  place  in  the  hands  of  the 
student  or  of  the  young  surgeon.   .  .  ." — Medical  Uecord. 

"...  We  can  recommend  this  book  with  confidence,  both  to  advanced  students  and 
practicing  surgeons ;  we  have  seen  nothing  of  the  kind  wo  like  so  well." — Canadian  Prac- 
tUUmer. 

"  This  work  by  Dr.  Brvant,  one  of  the  foremost  surgeons  of  New  York,  is  a  credit  to  our 
country  and  profession.  The  book  is  of  a  handy  size,  and  printed  from  gootl,  dear  type, 
and  yet.  with  thc>e  advantages,  it  has  not  been  condensed  so  as  to  deprive  it  of  the  value  of 
the  most  complete  work  on  operative  surgery.  In  addition  to  the  author's  clear  and  Ibrcible 
.style,  we  find  everytliing  splendidly  illustrated  that  could  in  any  sense  of  the  word  require 
illustrating." — Southern  Clinic. 

"  It  is  the  character  of  book  that  cverv  sur<roon  needs  for  readv  reference,  since  it  is  not 
always  that  one  has  time  to  refer  to  more  comprehensive  works,  or  to  atlases.  It  is  especially 
useful  for  physicians  in  the  country,  who  have  not  the  amount  of  surgical  practice  re<iuircd 
to  keep  them  familiar  with  the  entire  field  of  operation."— .-ImfriVd/i  Practitioner  and  Jieurs. 

"  The  author  of  this  work  seems  to  know  how.  in  the  briefest  space,  to  give  the  student 
of  surjerv  the  aid  necessary  '  to  acquire  established  facts,'  and  this  is  an  important  point  in 
a  book  of  this  kind.  The  text  is  most  fully  illustrated,  and  brings  the  subject  to  date."— 
-V<!r  Vorh  Medical  Times. 

New  York:    D.  APPLETON  &  CO.,  1,  3,  &  5  Bond  Street 


THE  RULES  OF 
ASEPTIC  AND  ANTISEPTIC  SURGERY. 

A  PRACTICAL  TREATISE  FOR  THE  USE  OF  STUDENTS 
AND  THE  GENERAL  PRACTITIONER. 

By  ARPAD    G.    GERSTER,   M.  D., 

PROFESSOR     OF     SURGERY     AT    THE    KEW     YORK    POLYCLINIC  ;      VISITING     SUKGEON    TO    THE 
GERMAN    HOSPITAL   AND   TO    MOUNT    SINAI    HOSPITAL,    NEW    YORK. 


8vo.     Illustrated  with  Two  Hundred  and  Forty-eight  Fine  Engravings. 
Cloth,  $5.00;    sheep,  $G.UO. 


The  attention  of  the  Medical  Profession  is  invited  to  the  followini,'  points  of 
excellence  in  this  work: 

It  deals  only  with  matters  of  practical  interest  to,  and  questions  that  are 
likely  to  arise  daily  in  the  work  of  the  practicing  physician.  Its  scope  is  a  terse 
yet  clear  exposition  of  the  principles  governing  modern  operative  surgery.  It 
enters  into  the  practical  details  of  all  the  varying  conditions  of  the  application 
of  the  antiseptic  method  as  brought  about  by  emergencies.  Every  important 
principle  is  clearly  illustrated  by  citations  from  actual  cases  occurring  in  the 
author's  practice. 

It  is  not  intended  to  take  the  place  of  any  text-hook  on  surgery,  but  rather 
to  supply  a  need  which  exists  in  every  work  on  the  subject  in  the  English  lan- 
guage, by  furnishing  information  on  the  subject  of  Asepsis  and  Antisepsis,  with 
which  no  book  on  surgery  deals  to  an  extent  demanded  by  modern  methods. 
It  is,  in  short,  a  supplement  to  all  surgical  text-books. 

The  illustrations  are  typo-gravures,  made  from  photographic  negatives  taken 
from  life,  and  are  marvels  of  beauty,  artistic  elegance,  and  fidelity;  each  illus- 
tration being  a  faithful  representation,  by  the  camera,  of  the  details  of  the 
application  of  all  important  antiseptic  dressings  and  apparatus,  approaching 
nearer  to  an  actual  demonstration  than  has  ever  before  been  attempted  to  bo 
done  in  any  medical  work.  With  the  exception  of  a  few  bacteriological  illns~ 
trations  taken  from  Koch,  Rosenbach,  and  Bumm,  the  illustrations  are  from 
negatives  made  in  the  operating-room,  and  are  of  a  character  now  for  the  first 
time  employed  in  a  medical  work. 


The  work  has  been  adopted  by  the  Medical  Department  of  the  United  States  Army. 


New  York:   D.   APPLETON  &  CO.,  Publishers,  1,  3,  &  5  Bond  Street. 


NOW  JIEADV,  A  NEW  EDITION  OF 

LECTURES  ON  ORTHOPEDIC  SUR- 

GERY  AND  DISEASES  OF  THE  JOINTS. 

By  LEWIS  A.  .SAYRE,  M.  D., 
Professor  of  Ortlinpeilic  Surgery  and  Clinical  Sm-L'cry  in  Bellevue  Hospital  Medical  Col- 
lege ;  Consulting  Surgeon  to  liellcvue  Hospital,  Charity  Hospital,  St.  Elizabeth's 
Hospital,  Northwestern  Hispensary,  etc.,  etc. 

Hlustratcd  with  324  Engravings  on  Wood.     1  vol.,  8vo.     Cloth,  $5.00  ;  sheep,  $6.00. 

"  This  edition  lias  been  thoroughly  revised  .ind  rearranged,  and  tlic  subjects 
classified  in  the  anatomical  and  patiiological  order  of  their  development.  Many 
of  the  chapters  have  been  entirely  rewritten,  and  several  new  ones  added,  and 
the  whole  work  brought  up  to  the  present  time,  with  all  the  new  iinprovement.s 
that  have  heen  developed  in  thi.s  department  of  surgery.  Many  new  engravings 
have  been  added,  each  illustrating  some  special  point  in  practice." — Author. 

NOTICES  OF  FORMER  EDITIONS. 

"The  name  of  the  author  is  a  sufficient  guarantee  of  its  excellence,  as  no  man  in 
America  or  elsewhere  has  devoted  such  unremitting  attention  for  the  past  thirty  years  to 
this  department  of  surgery,  or  given  to  the  profession  so  niauy  nesv  truths  and  laws  as 
applying  to  the  pathology  and  treatment  of  deformities." —  Western  Lancet. 

"  Dr.  Sayre  has  stamped  his  individuality  on  every  part  of  his  book.  Possessed  of  a 
taste  for  mechanics,  he  has  admirably  utilized  it  in  so  modifying  the  inventions  of  others 
as  to  make  them  of  far  greater  practical  value.  The  care,  patience,  and  perseverance 
which  he  exhibits  in  fulfilling  all  the  conditions  necessary  for  success  in  the  treatment 
of  this  troublesome  class  of  cases  are  worthy  of  all  praise  and  imitation." — Detroit  Review 
of  Medicine. 

"  Its  teaching  is  sound,  and  the  originality  throughout  very  pleasing ;  in  a  word,  no 
man  should  attempt  the  treatment  of  deformities  of  joint  affections  without  being  familiar 
wiih  the  views  contained  iu  these  lectures." — Caneiaa  Medical  and  Hurgical  Journal. 


RECENTLY  ISSUED,  A  NEW  EDITION  OF 

A  PRACTICxiL   MANUAL   ON   THE 

TREATMENT  OF  CLUB-FOOT. 

Fourth  edition.     Enlarged  and  corrected. 

By  LEWIS  A.  SAYRE,  M.  D., 

Professor  of  Orthopedic  Surgery  in  Belkvuc  Hospital   Medical  College  ;  Surgeon  to  Belle- 
vue and  Charity  Hospitals,  etc. 

1  vol.,  I2mo.     Illustrated.     Cloth,  §1.25. 

"  The  object  of  this  work  is  to  convey,  in  as  concise  a  manner  as  possible,  all 
the  practical  information  and  instruction  necessary  to  enable  the  general  practi- 
tioner to  apply  that  plan  of  treatment  which  has  been  so  successful  in  my  own 
hands.'' — Pre/are. 

"  The  book  will  very  well  satisfy  the  wants  of  the  majority  of  general  practitioners, 
for  whose  use,  as  stated,  it  is  intended." — New  i'ork  Medical  jounial. 


New  York:    D.  APPLETON  &  CO.,  1,  3,  &  5  Bond  Street. 


DICTIONARY  OF  MEDICINE, 


IN'CLUDINO 


GENERAL  PATHOLOGY,  GEXERAL  THERAPEITICS,  HYGIENE,  AND  THE 
DISEASES  PECULIAU  TO  WOMEN  AND  CHILDREN. 

BY  VARIOUS  WRITERS. 


RICHARD   QUAIN,  M.  D.,  F.  R.  S., 

PELLOW  OF  TUE   llOTAL  COLLEGE   OF   PHTJ^ICIASS,   AND   PHYSICIAN   TO   THE   IIorPITAL  FOB 
DISEASES  OF  THE   CUEST,   AT  BROMPTON,   ETr. 


TENTH    EDITION,   NOW   READY. 

In  one  large  8vo  volume  of  1,834  pages,  witii  1.38  Illustrations.    Half  morocco,  88.00. 
Sold  only  by  Subscription. 

Tills  work  is  primarily  a  Diotion.ary  of  Medicine,  in  wliieli  tlie  several  disea-sea 
are  fully  discussed  in  alplmbetieal  order.  The  description  of  each  includes  an  ac- 
count of  its  etiolofry  and  anatomical  <'haracters;  its  symptoms,  course,  duration, 
and  termination;  its  diagno.sis,  profrnosis,  and,  lastly,  its  treatment.  General 
Pathology  comprehends  articles  on  the  origin,  characters,  and  nature  of  disease. 

General  Therapeutics  includes  articles  on  the  several  classes  of  remedies, 
their  modes  of  action,  and  on  tho  methods  of  their  use.  The  articles  devoted  to 
the  subject  of  Hygiene  treat  of  the  causes  and  prevention  of  disease,  of  tho 
agencies  and  laws  affecting  public  health,  of  the  means  of  preserving  the  health 
of  the  individual,  of  the  construction  and  management  of  hospitals,  and  of  the 
nursing  of  the  sick. 

Lastly,  the  diseases  peculiar  to  women  and  children  are  discussed  under  their 
respective  headings,  both  in  aggregate  and  in  detail. 

"  A  goodly  volume  of  an  extremely  intercstinz  and  important  character.  Dr.  Quain 
has  .suceeedeil  in  brinfiin;;  together  and  eoiidiKting  a  work  niinibering  a  body  of  contiib- 
ulors  of  whose  co-operation  any  editor  might  t'eel  proud,  and  whoj^e  condjined  work  could 
not  fail  to  produce  a  hook  of  the  highest  autliority  and  practical  value.  It  is  n(tticeal)le 
that  the  most  recent  questions  arc  deilt  with,  and  are  all  treated  according  to  the  most 
recent  researches  and  knowledge." — British  Medical  Journal. 

"  This  new  Medical  Dictionary  contains  an  immense  mass  of  infonnation,  the  aggregate 
value  of  which  it  is  diffisuh  to  estimate,  but  which  may  tairly  be  expected  to  satisfy  the 
most  industrious  sludciu  of  medical  science.  A  very  wide  and  liberal  meaninf;  has  been 
given  to  the  word  M "dicine.  To  the  general  practitioners  we  can  most  heartily  recom- 
mend the  work;  and  it  will  find  many  readers  outside  the  pale  of  the  medical  profes- 
sion. It  should  have  a  place  in  at  least  every  public,  it  not  in  every  good  private, 
library.'' — Saturday  Keincic. 

"  The  articles  we  have  read  have  struck  us  as  models  of  clear  and  fluent  ceientific 
English.  The  volume  contains  many  articles  on  matters  of  general  interest  to  the  pu!)lic 
at  large,  though  not  less  important  on  that  account  to  the  practitioner." — iMndon  Speitalor. 


New  York :    D.  APPLETON  &  CO..  1,  3.  &  5  Bond  Street. 


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